The purpose of this study was to assess the value of ear endoscopy in cholesteatoma surgery and to demonstrate its consequence in improving surgical outcome. A total of 92 ears with acquired cholesteatoma (primary or secondary) were operated on. In this prospective study, 82 cases were operated on by using canal wall up (CWU) technique, and 10 cases were on operated on by using canal wall down (CWD) procedure. Endoscopically guided ear surgery was incorporated complementary to the microscope as a principal part in the procedure. Second-look endoscopic exploration was performed on some selected cases, depending on the finding during the primary surgery and the postoperative findings of clinical and computed tomographic studies. In the primary surgery after completion of microscopic cleaning, the overall incidence of intraoperative residuals detected with the endoscope was 22.8%. Sinus tympani was the most common site of intraoperative residuals in both CWU and CWD groups, followed by the facial recess and the undersurface of the scutum in the CWU cases. Reconstruction of the hearing mechanism was performed in the primary surgery in 86 cases (93.5%) and postponed to the second stage in only six cases (6.5%). Out of the 82 CWU cases, 35 second-look endoscopic explorations (42.7%) were performed. Three recurrences (8.6%) were identified. Two cases showed a tiny residual cholesteatoma pearl, and the third showed a larger open residual cholesteatoma filling the sinus tympani and extending to the aditus. In this series, no morbidity or complication was encountered secondary to the use of endoscopes in the mastoid or middle ear. Incorporating the endoscope into the surgical armamentarium in otology contributes much to the concept of minimally invasive surgery. Minimally invasive endoscopic ear surgery should be accepted as a new horizon in ear surgery. In this study, it became obvious that despite the use of the endoscope in conjunction with the operating microscope, 100% eradication of the disease still could not be achieved; however, the use of endoscopes did reduce the residual cholesteatoma rate.

The aim of this study was to assess the use of endoscopy in minimally invasive surgery of the cerebellopontine angle in cases of hemifacial spasm. Eighty patients with hemifacial spasm underwent endoscopically assisted microvascular decompression between October 1992 and October 1998, at the Ear, Nose, and Throat Department of Nord Hospital in Marseille, France. The microvascular decompression was performed via a minimally invasive retrosigmoid approach. The cerebellopontine angle was then explored by a 30-degree endoscope to visualize the root exit zone of the facial nerve and the precise location of the site of the conflict. Microvascular decompression was performed under the microscope. If the site was an artery, a Teflon sponge was inserted; if the site was a vein, it was coagulated and then dissected away from the facial nerve. In 80 patients seen regularly for at least 1 year of follow-up, and including patients operated on once or twice, the procedure was successful in 92.5% of patients, brought about improvement in 3.75% (96.25% success plus improvement), and failed in 3.75%. In relation to the type of conflict, success or improvement was experienced by 90.7% of patients with simple conflicts, 86.2% of patients with multiple conflicts, and 87.5% of patients with nutcracker conflicts. No major postoperative complication or mortality occurred in this series. No facial paresis or paralysis occurred immediately postoperatively. Three patients (3.25%) experienced delayed facial palsy. Postoperative cerebrospinal fluid leak occurred in 2 patients (2.5%) and was treated surgically. The principle of minimally invasive surgery in the cerebellopontine angle is gaining universal acceptance. The use of endoscopy in microvascular decompression for hemifacial spasm has helped tremendously in improving the results. In this study, the use of the endoscope enabled the authors to identify the site of the conflict in all cases, and to confirm the position of the Teflon sponge before closure.

The aim of this study was assessment of the use of endoscopy in minimally invasive surgery of the cerebellopontine angle in cases of trigeminal neuralgia. This study comprises 42 cases of trigeminal neuralgia that underwent operation with endoscopic-assisted microvascular decompression between October 1992 and October 1998. This study was performed in the Ear, Nose, and Throat Department, Nord Hospital, in Marseille, France. The decompression was performed by means of a minimally invasive retrosigmoid approach without a cerebellar retractor. The cerebellopontine angle was then explored by a 30-degree endoscope that gives a panoramic view of this space, with clear visualization of the trigeminal nerve from the pons to Meckel's cave, allowing for the identification of the precise location of the site of the conflict. Microvascular decompression was performed under the microscope by separating the offending vessel from the trigeminal nerve; separation was maintained by the insertion of a piece of Teflon. The site of conflict was detected at the root entry zone of the nerve in 35 patients (83.3%) and at Meckel's cave in 7 patients (16.7%). In 32 cases (76.2%), the type of contact between the vessel and the nerve was of the simple type (1 vessel coming in contact with the nerve in a single point); in 6 cases (14.3%), it was a multiple type (2 vessels touching the nerve in the same point); and in 4 cases (9.5%), it was a nutcracker type (2 vessels compressing the nerve between them). After at least 1-year follow-up and a single operation (cases that required a second operation for revision were considered failures), a successful result was obtained in 31 cases (73.8%), and an improvement was obtained in 4 cases (9.5%). The operation was a failure or early recurrence occurred in 7 cases (16.7%). Postoperative complications were rare. A cerebrospinal fluid leak occurred in only 1 case (2.4%) and was subsequently treated with lumbar puncture and a compressive bandage. The minimally invasive retrosigmoid endoscopic-assisted microvascular decompression is an acceptable treatment of primary trigeminal neuralgia. Endoscopy provides a unique way to explore the cerebellopontine angle and to identify the exact location of the neurovascular conflict.