Endoscopic Ear Surgery
Endoscopic Ear Surgery
Endoscopic Ear Surgery
1
| MD, Professor and Head of Department of Otorhinolaryngology,
AOUI Verona, University of Verona, Italy
2
| MD, Professor and Head of ENT Department, University Hospital of
Modena Policlinico, Modena, Italy
3
| MD, Department of Otorhinolaryngology, AOUI Verona, Italy
4 Endoscopic Ear Surgery – Surgical Manual of Standard Procedures
Correspondence address:
Davide Soloperto, MD
ENT Department, AOUI Verona, University of Verona, Italy
P.le A.Stefani 1, 37126 Verona, Italy
E-mail: [email protected]
Table of Contents
1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
4 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
6 Endoscopic Ear Surgery – Surgical Manual of Standard Procedures
Contributing Authors
Daniele Marchioni,
MD, Professor and Head of Department of Otorhinolaryngology,
AOUI Verona, University of Verona, Italy
Livio Presutti,
MD, Professor and Head of ENT Department,
University Hospital of Modena Policlinico, Modena, Italy
Davide Soloperto,
MD, Department of Otorhinolaryngology,
AOUI Verona, Italy
Endoscopic Ear Surgery – Surgical Manual of Standard Procedures 7
1 Introduction
The increasingly widespread acceptance of endoscopic sight are visually accessible and it is impossible to “look
techniques emerging in the past decades had – and still around corners”. The straight line of sight, a surgeon
has – a considerable impact on otology, and in particular, typically has to cope with when performing middle ear
on endoscopic surgery of the middle ear. During the surgery through a microscope, is associated with blind
1990s, endoscopy was adopted in otology only as a spots. These limitations can be compensated for by the
diagnostic modality and was never used for surgical complementary use of scopes, that provide a direction
procedures performed via the transtympanic route. of view other than 0 degree (e.g., 30°-scopes).33 Apart
Significant advancements have been made recently in the from a more comprehensive examination of the anatomy,
field of endoscopic-assisted middle ear surgery and have endoscopy allows to explore and better understand
provided the surgeon with an unprecedented, extremely the physiology and ventilation pathways of the middle
detailed view of the “in vivo” anatomy of the middle ear which can become blocked as a result of specific
ear.16, 32, 36 It is generally known that the middle ear is a very pathological alterations.9
small space, which – especially in some of its subunits
– is virtually not amenable to microscopic inspection. While instruments and auxiliary devices used in
The complexity of middle ear anatomy has prompted endoscopic ear surgery are similar to those of traditional
experienced otosurgeons to devise a host of techniques otosurgical procedures, curved instruments have been
for exploring areas that are difficult to visualize with adapted to the current otoscopic approaches – as
the operating microscope. Despite the illumination and determined by principles of good surgical practice –
magnification offered by the operating microscope, its resulting in longer and thinner instruments, with single or
use has proved to be associated with distinct limitations. double curvature, with various angles and more delicate
Only those structures that are located directly in the line of extremities (Figs. 1.1, 1.2).
Fig.|1.1 Left ear. Cadaveric dissection. An ear hook, curved to the left, Fig.|1.2 Right ear. Cadaveric dissection. Double-ended curette used for a
is used to mobilize the chorda tympani in a stenotic external auditory canal. complete exposure of the attic.
a b
Fig.|1.3 Right ear. Panoramic view of the tympanic cavity before (a) and after (b) use of CLARA visualization mode. These specific modes of the digital
image enhancement system is used effectively to brighten dark aspects of the image thus allowing for improved detail recognition.
8 Endoscopic Ear Surgery – Surgical Manual of Standard Procedures
a b c
Fig.|1.5 Tympanic membrane demonstrated by standard visualization (a). Views of the same site using CLARA (b) and CHROMA (c)
image enhancement modes.
a b
Fig.|1.6 Tympanic cavity demonstrated by standard visualization (a) and by use of CHROMA (b) image enhancement mode.
Note the highly vascularized area over the promontory region.
Endoscopic Ear Surgery – Surgical Manual of Standard Procedures 9
Fig.|2.1 Right ear. Schematic drawing of the tympanic cavity. Fig.|2.2 Right ear. 45° endoscopic view. The retrotympanum.
Chorda (ct); malleus (ma); incus (in); stapes (s); promontory (pr). Note the pyramidal eminence, the tympanic tract of the facial nerve,
By courtesy of Georg Thieme Verlag KG, Stuttgart, Germany.22 the stapedial region and the round window niche. The cochleariform
process is also visible.
10 Endoscopic Ear Surgery – Surgical Manual of Standard Procedures
Fig.|2.3 Right ear. 45° endoscopic view. Cholesteatoma involving Fig.|2.4 Right ear. 45° endoscopic view after retrotympanic
the superior retrotympanum. Note the extension to the superior cholesteatoma removal. The incus is removed and the tympanic tract
retrotympanum, between the ponticulus superiorly and the subiculum of the facial nerve is clearly identified.
inferiorly. The tegmen and the posterior pillar of round window niche
are covered by cholesteatoma matrix.
The superior limit of this space is represented by the examined the feasibility of gaining endoscopic access
ponticulus. The inferior anatomical boundary is a to this cavity.11,14 The morphology of the sinus tympani
prominent ridge (termed subiculum) that extends from was classified on the basis of intraoperative findings and
the styloid eminence to the posterior rim of the cochlear the anatomical variations of the ponticulus were also
window niche4, 8, 11,18, 29 (Figs. 2.3, 2.4). Recent anatomical described.
studies have been focused on the sinus tympani and
2.2. Epitympanum
The epitympanic space is a pneumatized portion of Depending on the conformation of the cog and tensor
the temporal bone superior to the mesotympanum. tympani fold, the boundary between the AES and the
Various authors have studied the anatomy of the PES can be the cog itself or can be drawn by a coronal
epitympanic compartments. From an anatomical point plane located at the level of the cochleariform process.
of view, it is possible to classify the epitympanum into The body and short process of the incus along with the
two distinct compartments: a larger and posterior one malleus head occupy most of the posterior epitympanic
(posterior epitympanic space, PES) and a smaller and space (Fig. 2.5).
anterior compartment (anterior epitympanic space, AES).
Fig.|2.6 Right ear. The epitympanic diaphragm. The incudomalleolar Fig.|2.7 Left ear. The isthmus. Cochleariform process, malleus and
lateral fold is shown through the 0°-scope. incudostapedial joint are seen endoscopically. The isthmus is checked in
order to remove blockage of the ventilation pathway to the epitympanum.
2.3. Hypotympanum
The hypotympanum is part of the tympanic cavity that the hypotympanum corresponds to the juncture of its
lies beneath the level of the eardrum at the junction of outer and inner walls and it separates the tympanic
the tympanic and petrous parts of the temporal bone. It cavity from the jugular bulb. The inferior aspect of the
is usually shaped like an irregular bony groove, extending hypotympanum varies considerably due to the presence
from the finiculus posteriorly toward the eustachian of bony recesses on its floor and its close proximity to the
tube orifice anteriorly (Fig. 2.8). The inferior aspect of inferior retrotympanum24, 25 (Fig. 2.9).
Fig.|2.8 Left ear. Endoscopic cadaveric view of the hypotympanum. Fig.|2.9 Left ear. Inferior retrotympanum and round window chamber.
The finiculus, delineating the posterior boundary of this space, and the The socalled fustis, extending from the styloid complex into round window
eustachian tube orifice anteriorly, are shown. Note the projection of the niche, indicates the position of the round window membrane.
internal carotid artery anteriorly and the bony crests at the level of the
floor of the hypotympanum, corresponding to the jugular bulb projection.
12 Endoscopic Ear Surgery – Surgical Manual of Standard Procedures
Fig.|2.10 Right ear. Endoscopic cadaveric dissection. Protympanic space. Fig.|2.11 Left ear. Endoscopic view of the tubaric orifice and
protympanic cellularity.
2.4. Protympanum
The protympanic space is a pneumatic portion of the surgery, the protympanic space is less important than
middle ear that lies anteriorly to the mesotympanum, other spaces because chronic disease seldom involves
inferiorly to the AES, and superiorly to the hypotympanum26 this recess, however, it is yet noteworthy that some
(Figs. 2.10–2.12). The cochleariform process and the tensor important structures are located there. The protympanum
fold with the tensor tympani canal represent the upper can be divided into two portions: the supratubal recess
limit of the protympanic space, while it is commonly superiorly, and the eustachian tube orifice inferiorly.
bounded posteriorly by the promontory.13 In middle ear
3.1.1. Rationale
Although in general microscopic myringoplasty is wide access, which otherwise is fraught with the risk of
considered a safe operation, the endoscopic technique postoperative external auditory canal (EAC) stenosis or
is probably even safer due to the absence of an external anomalous healing processes.
incision, which minimizes the risk of postoperative The direct visualization of the entire medial aspect of the
wound infection or hematoma formation. The procedure middle ear (including the facial nerve) adds support to
obviates the need for bone drilling to create an adequately that concept.1,10
Endoscopic Ear Surgery – Surgical Manual of Standard Procedures 13
Fig.|3.1 Left ear. Subtotal perforation of the tympanic membrane. Fig.|3.2 Left ear. Magnified aspect of middle ear structures visible
through the perforation. Promontory, protympanic space and stapes
are shown.
Fig.|3.3 Left ear. After cruentation of of the perforation margins, Fig.|3.4 Left ear. Retrotympanic region viewed through the 45°-scope.
the tympanomeatal flap is harvested and detached from the malleus,
clearly exposing the anterior annulus.
14 Endoscopic Ear Surgery – Surgical Manual of Standard Procedures
Fig.|3.5 Left ear. A circumferential island of cartilage is formed as Fig.|3.6 Left ear. The denuded portion of cartilage will be positioned
determined by the eardrum defect. The perichondrial layer on the laterally to the tympanic residues, fitting through the perforation, and the
posterior surface of the cartilage is modeled while maintaining adherence perichondrium will be medial to the tympanic residues and positioned
to the cartilage. A microhook, angled to the left, working length 5.5 cm, under and anteriorly to the malleus handle. The tympanomeatal flap is
is used to insert the graft through the external auditory canal. then repositioned over the graft.
A circumferential island of cartilage is formed as The cartilage graft is finally positioned by passing it above
determined by the eardrum defect. The perichondrial the malleus handle and making contact with the medial
layer on the posterior surface of the cartilage is modeled face of the residual eardrum (Figs. 3.5, 3.6).
making sure that adherence to the cartilage is maintained.
3.2.1. Rationale
Since the introduction of the classic stapedectomy surgeon may choose a close-up view and then swiftly
technique by Shea,28 many different procedures have change to panoramic vision simply by advancing or
been described in the literature from an microscopic withdrawing the scope. Another option is on-axis rotation
point of view.5, 6 The operating microscope provides mag- of the scope in order to obtain a circumferential view. In
nified images of highest quality, however with line of vi- cases of facial prolapse or dehiscence, use of the scope
sion being limited to objects located straight ahead, and can be very helpful in evaluating the stapes footplate
the field of view reaching only the narrowest segment of (platina) and performing stapedotomy in the right position,
the ear canal. The main advantages of the endoscopic eliminating the risk of iatrogenic injury to the facial nerve.
approach are that there is virtually no trauma to the Besides, the endoscopic technique is used effectively
chorda tympani in cases where there is no curetting or in cases of stapes malformation15 or in revision surgery
drilling, and that one has excellent visualization of the where meticulous anatomical scrutiny is needed to better
anterior crus of the stapes, its superstructure, and the understand the real relationship between the surrounding
oval window niche. In the course of the operation, the anatomical structures with the microscope.
Endoscopic Ear Surgery – Surgical Manual of Standard Procedures 15
Fig.|3.7 Left ear. Normal appearence of the tympanic membrane. Fig.|3.8 The skin of the external auditory canal is incised from the
5 o’clock to the 12 o’clock position.
Fig.|3.9 Left ear. The tympanomeatal flap is harvested and raised until Fig.|3.10 The stapedial region is exposed. The flap is elevated with
the fibrous annulus is revealed, using a curved otologic dissector, a delicate cupped ear forceps, 1 x 4.5 mm, working length 8 cm.
working length 5.5 cm. Cottonoids saturated with adrenalin solution Occasionally, the posterior bony part of the EAC can be curetted or
facilitate hemostasis during this surgical step. drilled to facilitate exposure of the incudostapedial joint. When curetting
(or drilling) is needed, special care is given to the chorda tympani to
prevent causing iatrogenic damage to this structure.
Fig.|3.11 Left ear. High-definition endoscopic view of incudostapedial Fig.|3.12 Left ear. High-definition endoscopic view of incudostapedial
joint. Stapedial tendon, posterior crus and stapes footplate are clearly joint visualized with a 45°-scope. Note the anterior and posterior crura,
exposed. A micro hook curved to the right is used to confirm the presence stapes footplate and facial nerve which can be appreciated in great detail.
of stapes fixation.
16 Endoscopic Ear Surgery – Surgical Manual of Standard Procedures
Fig.|3.13 Left ear. The stapedial tendon is divided with a curved Fig.|3.14 The stapes superstructure is downfractured with delicate force
microscissors. and removed, leaving the footplate intact. A small drill or a laser may also
be used for this purpose.
Attention is directed at the facial nerve to ensure that it is An endoscopic close-up view of the oval window and
not prolapsed onto the footplate. Following a brief test on the prosthesis offers better control of the final result of
the status of the ossicular chain, the incudostapedial joint surgery. The tympanomeatal flap is repositioned and
is disarticulated sharply in an anteroposterior plane. The sealed with Gelfoam on the external auditory canal
stapedial tendon is divided with small curved scissors (Fig. 3.17).
(Fig. 3.13). The stapes superstructure is downfractured with
delicate force and removed, leaving the footplate intact
(Fig. 3.14). A platinotomy is created at the midportion or
the posterior portion of the footplate with a standard small
drill (Fig. 3.15). A standard teflon or titanium prosthesis
(0.5 mm in diameter and usually 4.75 mm longer ) is
calibrated by measuring the distance from the footplate to
the medial surface of the incus. The prosthesis is placed
between the oval window and the incus. The malleus
is carefully palpated to ensure unimpeded movement
of the ossicles all the way through the prosthesis
(Fig. 3.16).
Fig.|3.16 The stapes prosthesis is placed between the oval window Fig.|3.17 The tympanomeatal flap is repositioned.
and the incus. Placement of the prosthesis is the most challenging
surgical step because this maneuver is performed with one hand only.
Endoscopic Ear Surgery – Surgical Manual of Standard Procedures 17
3.3.1. Rationale
The transmeatal endoscopic approach has shown to be surgical treatment strategy, which should be based on the
a feasible and safe minimally invasive technique for the findings according to the cholesteatoma classification,
exposure and excision of cholesteatoma confined to the differentiating between the following groups:
middle ear cavity and its extensions.17, 34, 35 Improved eradi-
cation of the cholesteatoma by endoscopic removal of 1. Primary acquired cholesteatoma.
hidden pathology from the facial recess, sinus tympani, 2. Secondary acquired cholesteatoma.
anterior epitympanic space, and eustachian tube is one 3. Congenital cholesteatoma.
of the well-accepted benefits of endoscopic ear surgery
(EES)2, 3, 23 (Fig. 3.18).
The pathogenesis of cholesteatoma remains incompletely
Considering that decision-making on the surgical understood. From recent studies with endoscopic
technique to be adopted is largely dependent of the techniques new theories about the genesis of the primary
extent of disease, preoperative otoscopic and radiological acquired cholesteatoma in the attic region can be
findings can play a crucial role in defining an individualized postulated.12, 27, 30, 31
a b c d
Fig.|3.19 Schematic drawing showing the range of indications for endoscopic ear surgery (EES) (a–c) as determined by the site of pathology.
The extension of disease into the tympanic cavity is highlighted in glaring red. Limited attic cholesteatoma (a). Cholesteatoma involving the tympanic
cavity without mastoid cell involvement (b). Attic cholesteatoma with extension to the antrum and periantral cells in a patient with a small mastoid
exhibiting a poorly-pneumatized cell system (in this case, a transcanal endoscopic open approach is indicated). Contraindication (d): cholesteatoma
with involvement of the mastoid air cells (in this case, a microscopic approach is required). By courtesy of Georg Thieme Verlag KG, Stuttgart, Germany.22
18 Endoscopic Ear Surgery – Surgical Manual of Standard Procedures
Fig.|3.20 Right ear. Transcanal endoscopic approach. The examination Fig.|3.21 Epinephrine solution is injected in the posterior portion of the
reveals an epitympanic cholesteatoma and the mesotympanum is found ear canal. The incision is made clockwise passing from the 3 o’clock to
to be well-pneumatized. the 9 o’clock position, 1.5 to 2 cm from the annulus, using an angled
round knife.
Fig.|3.22 The pars flaccida is accurately dissected from the Fig.|3.23 The cholesteatoma is located laterally with respect to the
cholesteatoma sac, passing from top to bottom. The tympanomeatal ossicular chain. The drum is detached from the umbo.
flap is transposed inferiorly on the malleus.
Endoscopic Ear Surgery – Surgical Manual of Standard Procedures 19
The Prussak space and the ossicular chain are now sure that no residual disease is left behind. Isthmus and
evaluated and particular attention is paid to look for signs tensor fold are evaluated to restore normal ventilation in
of erosion of the chain (Fig. 3.24). If this is not confirmed, case of blockage (Fig. 3.25). Once a tragal incision has
then the standard surgical maneuvers are carried out been made, a piece of cartilage with perichondrium is
carefully in order not to damage this vulnerable structure. used to reconstruct the scutum. The tympanomeatal flap
After complete removal of cholesteatoma, the middle ear is finally repositioned (Figs. 3.26, 3.27).
cavity is thoroughly inspected with a 45°-scope to make
Fig.|3.24 View of the ossicular chain upon complete exposure. Fig.|3.25 Final aspect of the tympanic cavity after cholesteatoma
removal. Careful inspection of the ossicular chain is particularly aimed
at detecting signs of erosion. All spaces of the tympanic cavity are
thoroughly inspected to check for residual disease.
Fig.|3.26 The lateral bony wall of the attic is reconstructed using a tragal Fig.|3.27 The tympanomeatal flap is repositioned and a few Gelfoam
cartilage graft. pledgets are placed in the EAC.
20 Endoscopic Ear Surgery – Surgical Manual of Standard Procedures
Case 4
Congenital Cholesteatoma of the Left Ear
The tympanic membrane is examined with a 0°-otoscope. meatal flap is harvested. The cholesteatoma is found to
A huge cholesteatoma of the middle ear is revealed occupy the entire tympanic cavity (Fig. 3.29). With gentle
(Potsic stage III,21 Fig. 3.28). Following infiltration with a dissection, the cholesteatoma sac is detached from the
topical solution of anestetic and adrenalin, the tympano- mesotympanic and protympanic spaces (Fig. 3.30).
Fig.|3.28 Endoscopic view of the left tympanic membrane. Fig.|3.29 The tympanomeatal flap is completely harvested.
Cholesteatoma is revealed in the mesotympanum. The tympanic cavity is extensively occupied by the cholesteatoma.
Only the long process of malleus is visualized.
Fig.|3.30 The cholesteatoma sac is gently dissected. Fig.|3.31 The cholesteatoma matrix is gradually dissected. The stapes is
found to be eroded, the platina is clearly visualized.
Endoscopic Ear Surgery – Surgical Manual of Standard Procedures 21
Fig.|3.32 The malleus head is transected to expose the medial aspect of Fig.|3.33 The use of angled instruments is critical in removing the
the epytimpanum. Owing to cholesteatoma invasion, the chorda tympani holesteatoma matrix. Note the platina and the course of the facial nerve.
also needs to be transected. The promontory is gradually exposed,
thereby removing the cholesteatoma matrix.
The head of malleus is sectioned and removed in order using a 45°-scope and angled instruments (Fig. 3.34). At
to expose the medial aspect of the epitympanum (Figs. the end of surgery, an ossiculoplasty is performed with
3.31–3.33). The cholesteatoma is completely removed the remodelled head of malleus (Figs. 3.35–3.37).
Fig.|3.34 At the end of surgery, there are no signs of residual disease. Fig.|3.35 Protympanic space and Eustachian tube orifice are free
All sectors are explored with a 45°-scope. of disease.
Fig.|3.36 Ossiculoplasty with the remodelled malleus head is performed Fig.|3.37 Endoscopic view at the end of the surgery. A piece of Gelfoam
to reconstruct the sound-conducting system. Pieces of Gelfoam are is applied to reinforce the attic and the tympanomeatal flap is laid back to
placed around the malleus to provide stable support. return to its anatomical position.
22 Endoscopic Ear Surgery – Surgical Manual of Standard Procedures
Fig.|3.38 Left ear. After tympanomeatal flap elevation, the retrotympanum Fig.|3.39 A mastoid cortical bone fragment is used to reconstruct the
is clearly seen through a transcanal endoscopic approach. Note the ossicular chain.
ponticulus, a bony ridge extending from the pyramidal process to the
promontory region separating the sinus tympani from the posterior
tympanic sinus. The facial nerve and the stapes are clearly demonstrated.
Fig.|3.41 The ossicular reconstruction is stabilized with pieces of Fig.|3.42 A temporalis fascia graft is placed over the ossiculoplasty
Gelfoam positioned all around. and beneath the drum.
Fig.|3.43 The tympanomeatal flap is laid back down over the graft
and the ossiculoplasty.
24 Endoscopic Ear Surgery – Surgical Manual of Standard Procedures
4 References
20. PALVA T, RAMSAY H. Incudal folds and epitympanic 28. SHEA JJ Jr. A personal history of stapedectomy.
aeration. Am J Otol 1996;17(5):700–8. Am J Otol 1998;19(5 Suppl):S2-12.
21. POTSIC WP, SAMADI DS, MARSH RR, 29. STEINBRUGGE H. On sinus tympani. Arch
WETMORE RF. A staging system for congenital Otolaryngol. 1889(8):53–7.
cholesteatoma. Arch Otolaryngol Head Neck Surg 30. SUDHOFF H, TOS M. Pathogenesis of attic
2002;128(9):1009–12. cholesteatoma: clinical and immunohistochemical
support for combination of retraction theory and
22. PRESUTTI L, MARCHIONI D. Endoscopic Ear proliferation theory. Am J Otol 2000;21(6):786–92.
Surgery: Principles, Indications, and Techniques.
New York: Thieme; 2014. (ISBN No. 9783131630414). 31. SUDHOFF H, TOS M. Pathogenesis of sinus
cholesteatoma. Eur Arch Otorhinolaryngol
23. PRESUTTI L, MARCHIONI D, MATTIOLI F, VILLARI D, 2007;264(10):1137–43. doi:10.1007/s00405-007-
ALICANDRI-CIUFELLI M. Endoscopic management 0340-y.
of acquired cholesteatoma: our experience.
32. TARABICHI M. Endoscopic management of acquired
J Otolaryngol Head Neck Surg 2008;37(4):481–7.
cholesteatoma. Am J Otol 1997;18(5):544–9.
24. PROCTOR B. Surgical anatomy of the posterior 33. TARABICHI M. Endoscopic middle ear surgery.
tympanum. Ann Otol Rhinol Laryngol Ann Otol Rhinol Laryngol 1999;108(1):39–46.
1969;78(5):1026–40.
34. TARABICHI M. Endoscopic management of
25. PROCTOR B, BOLLOBAS B, NIPARKO JK. Anatomy limited attic cholesteatoma. Laryngoscope
of the round window niche. Ann Otol Rhinol Laryngol 2004;114(7):1157–62. doi:10.1097/00005537-
1986;95(5 Pt 1):444–6. 200407000-00005.
35. TARABICHI M. Transcanal endoscopic management
26. SAVIC D, DJERIC D. Anatomical variations and of cholesteatoma. Otol Neurotol 2010;31(4):580–8.
relations in the medial wall of the bony portion of the doi:10.1097/MAO.0b013e3181db72f8.
eustachian tube. Acta Otolaryngol 1985;99
(5-6):551–6. 36. THOMASSIN JM, KORCHIA D, DORIS JM.
Endoscopic-guided otosurgery in the prevention
27. SEMAAN MT, MEGERIAN CA. The pathophysiology of residual cholesteatomas. Laryngoscope
of cholesteatoma. Otolaryngol Clin North Am 1993;103(8):939–43. doi:10.1288/00005537-
2006;39(6):1143–59. doi:10.1016/j.otc.2006.08.003. 199308000-00021.
26 Endoscopic Ear Surgery – Surgical Manual of Standard Procedures
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Endoscopic Ear Surgery – Surgical Manual of Standard Procedures 27
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28 Endoscopic Ear Surgery – Surgical Manual of Standard Procedures
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Endoscopic Ear Surgery – Surgical Manual of Standard Procedures 29
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280035
Please note: The burrs displayed are not included in the rack.
46 Endoscopic Ear Surgery – Surgical Manual of Standard Procedures
39552 B
Please note: The instruments displayed are not included in the sterilizing and storage trays.
Endoscopic Ear Surgery – Surgical Manual of Standard Procedures 47
20 7120 33
33 mm
7.5 mm
252680
53 mm
7.5 mm
252681
20 7120 33
31 mm
5.5 mm
252660
51 mm
5.5 mm
252661
31 mm
5.5 mm
252690
51 mm
5.5 mm
252691
252680 252681
1 350110 S 350110 M
2 350120 S 350120 M
3 350130 S 350130 M
4 350140 S 350140 M
5 350150 S 350150 M
6 350160 S 350160 M
7 350170 S 350170 M
1 350210 S 350210 M
2 350220 S 350220 M
3 350230 S 350230 M
4 350240 S 350240 M
5 350250 S 350250 M
6 350260 S 350260 M
7 350270 S 350270 M
50 Endoscopic Ear Surgery – Surgical Manual of Standard Procedures
252680 252681
3 350330 S 350330 M
4 350340 S 350340 M
5 350350 S 350350 M
6 350360 S 350360 M
7 350370 S 350370 M
9 350690 S 350690 M
6 350960 S 350960 M
3 350730 S 350730 M
Endoscopic Ear Surgery – Surgical Manual of Standard Procedures 51
1 330110 ES 330110 S
2 330120 ES 330120 S
3 330130 ES 330130 S
4 330140 ES 330140 S
5 330150 ES 330150 S
6 330160 ES 330160 S
7 330170 ES 330170 S
1 330210 ES 330210 S
2 330220 ES 330220 S
3 330230 ES 330230 S
4 330240 ES 330240 S
5 330250 ES 330250 S
6 330260 ES 330260 S
7 330270 ES 330270 S
52 Endoscopic Ear Surgery – Surgical Manual of Standard Procedures
3 330330 ES 330330 S
4 330340 ES 330340 S
5 330350 ES 330350 S
6 330360 ES 330360 S
7 330370 ES 330370 S
4 330440 ES 330440 S
6 330460 ES 330460 S
Size in mm
extra short short
(diameter x length)
254000
254100
254200
254235 Saw Blade, blade thickness 0.35 mm, working length 12 mm,
package of 12, for use with Osseo Scalpel, Micro Saw 254200
254300
39553 A
Dermatomes
Special features:
For removing skin and mucosa
Dermaplaning for obtaining small|pieces|
of skin from behind the ear
Can be easily adapted to motor
Optimal setting of the incision depth
Lightweight construction
Dermatome – Accessories
39554 A
Innovative Design
Dashboard: Complete overview with intuitive Automatic light source control
menu guidance Side-by-side view: Parallel display of standard
Live menu: User-friendly and customizable image and the Visualization mode
Intelligent icons: Graphic representation changes Multiple source control: IMAGE1 S allows
when settings of connected devices or the entire the simultaneous display, processing and
system are adjusted documentation of image information from
two connected image sources, e.g., for hybrid
operations
TC 200EN
Specifications:
HD video outputs - 2x DVI-D Power supply 100 – 120 VAC/200 – 240 VAC
- 1x 3G-SDI Power frequency 50/60 Hz
Format signal outputs 1920 x 1080p, 50/60 Hz Protection class I, CF-Defib
LINK video inputs 3x Dimensions w x h x d 305 x 54 x 320 mm
USB interface 4x USB, (2x front, 2x rear) Weight 2.1|kg
SCB interface 2x 6-pin mini-DIN
TC 300
Specifications:
Camera System TC 300 (H3-Link)
Supported camera heads/video endoscopes TH 100, TH 101, TH 102, TH|103,|TH|104, TH 106
(fully compatible with IMAGE1 S)
22 2200 55-3, 22 2200 56-3, 22 2200 53-3, 22 2200 60-3, 22 2200 61-3,
22 2200 54-3, 22 2200 85-3
(compatible without IMAGE1 S technologies CLARA, CHROMA, SPECTRA*)
LINK video outputs 1x
Power supply 100 – 120 VAC/200 – 240 VAC
Power frequency 50/60 Hz
Protection class I, CF-Defib
Dimensions w x h x d 305 x 54 x 320 mm
Weight 1.86 kg
Specifications:
IMAGE1 FULL HD Camera Heads IMAGE1 S H3-Z
Product no. TH 100
Image sensor 3x 1/3" CCD chip
Dimensions w x h x d 39 x 49 x 114 mm
Weight 270 g
Optical interface integrated Parfocal Zoom Lens,
f = 15 – 31 mm (2x)
Min. sensitivity F 1.4/1.17 Lux
Grip mechanism standard eyepiece adaptor
Cable non-detachable
Cable length 300 cm
Specifications:
IMAGE1 FULL HD Camera Heads IMAGE1 S H3-ZA
Product no. TH 104
Image sensor 3x 1/3" CCD chip
Dimensions w x h x d 39 x 49 x 100 mm
Weight 299 g
Optical interface integrated Parfocal Zoom Lens,
f = 15 – 31 mm (2x)
Min. sensitivity F 1.4/1.17 Lux
Grip mechanism standard eyepiece adaptor
Cable non-detachable
Cable length 300 cm
Endoscopic Ear Surgery – Surgical Manual of Standard Procedures 63
Monitors
9619 NB
9826 NB
Monitors
Optional accessories:
9826 SF Pedestal, for monitor 9826 NB
9626 SF Pedestal, for monitor 9619 NB
Specifications:
KARL STORZ HD and FULL HD Monitors 19" 26"
Desktop with pedestal optional optional
Product no. 9619 NB 9826 NB
Brightness 200 cd/m2 (type) 500 cd/m2 (type)
Max. viewing angle 178° vertical 178° vertical
Pixel distance 0.29 mm 0.3 mm
Reaction time 5 ms 8 ms
Contrast ratio 700:1 1400:1
Mount 100 mm VESA 100 mm VESA
Weight 7.6 kg 7.7 kg
Rated power 28 W 72 W
Operating conditions 0 – 40°C 5 – 35°C
Storage -20 – 60°C -20 – 60°C
Rel. humidity max. 85% max. 85%
Dimensions w x h x d 469.5 x 416 x 75.5 mm 643 x 396 x 87 mm
Power supply 100 – 240 VAC 100 – 240 VAC
Certified to EN 60601-1, EN 60601-1, UL 60601-1,
protection class IPX0 MDD93/42/EEC,
protection class IPX2
Endoscopic Ear Surgery – Surgical Manual of Standard Procedures 65
Workflow-oriented use
Patient
Entering patient data has never been this easy. AIDA seamlessly
integrates into the existing infrastructure such as HIS and PACS.
Data can be entered manually or via a DICOM worklist.
All important patient information is just a click away.
Checklist
Central administration and documentation of time-out. The checklist
simplifies the documentation of all critical steps in accordance with
clinical standards. All checklists can be adapted to individual needs
for sustainably increasing patient safety.
Record
High-quality documentation, with still images and videos being
recorded in FULL HD and 3D. The Dual Capture function allows for
the parallel (synchronous or independent) recording of two sources.
All recorded media can be marked for further processing with just
one click.
Edit
With the Edit module, simple adjustments to recorded still images
and videos can be very rapidly completed. Recordings can be quickly
optimized and then directly placed in the report.
In addition, freeze frames can be cut out of videos and edited and
saved. Existing markings from the Record module can be used for
quick selection.
Complete
Completing a procedure has never been easier. AIDA offers a large
selection of storage locations. The data exported to each storage
location can be defined. The Intelligent Export Manager (IEM) then
carries out the export in the background. To prevent data loss,
the system keeps the data until they have been successfully exported.
Reference
All important patient information is always available and easy to access.
Completed procedures including all information, still images, videos,
and the checklist report can be easily retrieved from the Reference module.
68 Endoscopic Ear Surgery – Surgical Manual of Standard Procedures
Equipment Cart
UG 540
Endoscopic Ear Surgery – Surgical Manual of Standard Procedures 69
UG 310
UG 410
UG 510
70 Endoscopic Ear Surgery – Surgical Manual of Standard Procedures
Notes:
with the compliments of
KARL STORZ — ENDOSKOPE