Braz. j. . vol.83 número6

BrazJOtorhinolaryngol.2017;83(6):730---731

www.bjorl.org

Brazilian

Journal

of

OTORHINOLARYNGOLOGY

LETTER

TO

THE

EDITOR

The

outer

diameter

of

the

endoscope

is

important

when

performing

endoscopic

transcanal

myringoplasty

O

diâmetro

externo

do

endoscópio

é

importante

ao

realizar

a

miringoplastia

endoscópica

transcanal

DearEditor,

We would like to address the manuscript entitled ‘‘Transcanal endoscopic myringoplasty: A case series in a universitycenter’’byGarciaetal.1_{The workisexcellent.}

However,webelievethattheappropriateapplicationofthe technology, and the surgical indications, are not entirely clear.

The authors write, in the Materials and Methods: ‘‘All patients older than 12years with a diagnosis of non-suppurative,non-cholesteatomatousCOMsequela,or with traumaticperforationswithout spontaneousresolution for morethanthreemonths, wereincluded inthe study.The diagnosis was based on anamnesis, physical examination, audiometry,andimpedanceaudiometry’’.1_{Theseinclusion}

criteriaarevague.Previousstudieshavesuggestedthatmost traumatic perforations tend to heal spontaneously within 3monthsofinjury.2_{Certainsimple,noninvasivetreatments}

facilitatetheclosureofsubacutetympanicmembrane per-forations; these include topical FGF-2 application3 _and

Gelfoampatching.Thus,endoscopiccartilagemyringoplasty simply increases medical costs, and complications, when traumaticperforationsdonotundergospontaneous resolu-tionwithin3months.Inaddition,theauthorsdonotmake itclearwhetherperforationswithotitismediaofthetype associated with granulation tissue were included. Endo-scopicmyringoplastyaloneisnotreliableinsuchpatients; mastoidectomyshouldalsobeperformed.

DOIoforiginalarticle:

http://dx.doi.org/10.1016/j.bjorl.2015.05.012

夽 _{Pleasecitethisarticle as:LouZ.The outerdiameterofthe}

endoscope is important when performing endoscopic transcanal

myringoplasty.BrazJOtorhinolaryngol.2017;83:730---1.

Theauthorswrite,inthe MaterialsandMethods:‘‘The techniqueandthesurgicalinstrumentsusedwerethesame as in routine surgeries with microscope, except for the non-useof themicroscope andotologic speculum,andthe use of the Storz rigid endo-scopes, 4mm diameter and 18cm long, at 0◦ _{angulation (Karl StorzGmbH & Co.} KG-Tuttlingen, Germany)’’.1 _{The authors do not report the}

statusoftheExternalAuditoryCanal(EAC).Wehavefound that endoscopic myringoplasty is particularly difficult in patients withtortuous or extremely narrow EACs,and in thosewithanymass(suchasasmallosteoma)thatreduces theendoscopicfieldofview.This isbecausesimultaneous insertionoftheendoscopeandtherequisitesurgical instru-ments crowds the surgical field. Adult EACs of diameter <4.0mmareconsiderednarrow.4_{Thediameterofthe}

micro-instrumentusedduringotologyexceeds1mm.Thesurgical fieldbecomesverycrowdediftheEACis<4.0mmin diam-eter,particularlyifanendoscope4.0mminouterdiameter isemployed.However,inchildren,Itoetal.5_believedthat

endoscopicmyringoplastywasfeasiblewhenthedifference between thediameter ofthe endoscopeand thesmallest EACdiameterwas>0.5mm. Itwasdangeroustoemploya 2.7mm-diameterendoscopeduringpediatricmyringoplasty when the diameterof the EAC was <3.2mm. Thus, tran-scanalendoscopicmyringoplastymaybedifficultinchildren aged12---16yearsifanendoscope4.0mminouterdiameter isused.Furthermore,inmostcases,onlyonehandisfreeto performendoscopicmyringoplastybecausetheother must holdtheendoscope. Ahematoma(withsubsequent bleed-ing)candevelopiftheendoscopecontactstheEACorthe freshenedperforationmarginsofpediatricpatientsexhibit chronicEACinflammation,aremnanteardrum,orfungal oti-tisexterna. Amassivebleedmayobstruct theendoscopic field-of-view, thus hinderingsurgery. Although application ofaspongesoakedinepinephrine(1:100,000dilution)fora fewminutesmayaffordadequate hemostasis,one-handed surgery usingan endoscopic techniqueprolongs the oper-ation.However,thesurgeoncanuse onehandtoaspirate blood andthe other tofreshenthe perforation marginsif the bimanual microscopic approachis employed. In addi-tion,theauthorswrite,intheResultssection:‘‘Asforthe surgicaloutcomeat postoperativeotoscopy,complete clo-sure of the perforation wasobserved in 86.4% (n=19) of patientsthreemonthsafterintervention.’’1_{The follow-up}

timewasshortandthusthereportedsuccessrateisnot com-pletelyreliable.Mostauthorssuggestthatfollow-upforat

http://dx.doi.org/10.1016/j.bjorl.2017.03.003

1808-8694/©2017Associac¸˜aoBrasileiradeOtorrinolaringologiaeCirurgiaC´ervico-Facial.PublishedbyElsevierEditoraLtda.Thisisanopen

LETTERTOTHEEDITOR 731

least1yearisnecessary;re-perforationaftermyringoplasty ispossibleduringthistime.6

Inbrief,thetranscanalendoscopicapproachisexcellent for performing cartilage myringoplasty, reducingboth the surgicaltimeandcomplications.However,boththesurgical indications,andcarefulconsiderationoftheouterdiameter oftheendoscope,areveryimportant,andlong-term follow-upisrequired.

Conflicts

of

interest

Theauthordeclaresnoconflictsofinterest.

References

1.GarciaLdeB,MoussalemGF,AndradeJS,Mangussi-GomesJ,Cruz OL, PenidoNdeO,etal.Transcanalendoscopicmyringoplasty: a caseseries in a university center. Braz J Otorhinolaryngol. 2016;82:321---5.

2.JellingeME,KristensenS,LarsenK.Spontaneousclosureof trau-matictympanicmembraneperforations:observationalstudy.J LaryngolOtol.2015;129:950---4.

3.LouZ,HuangP,YangJ,XiaoJ,ChangJ.DirectapplicationofbFGF withoutedgetrimmingonhumansubacutetympanicmembrane perforation.AmJOtolaryngol.2016;37:156---61.

4.ColeRR,JahrsdoerferRA.Theriskofcholesteatomaincongenital auralstenosis.Laryngoscope.1990;100:576---8.

5.ItoT,KubotaT, WatanabeT,FutaiK,Furukawa T,KakehataS. Transcanalendoscopicearsurgeryforpediatricpopulationwith anarrowexternalauditorycanal.IntJPediatrOtorhinolaryngol. 2015;79:2265---9.

6.MohamadSH,KhanI,HussainSS.Iscartilagetympanoplastymore effectivethanfasciatympanoplasty.Asystematicreview.Otol Neurotol.2012;33:699---705.

ZhengcaiLou

TheAffiliatedYiWuHospitalofWenzhouMedical University,DepartmentofOtorhinolaryngology,Zhejiang, China