In recent years, transcanal endoscopic ear surgery (TEES) has become popular for the treatment of middle ear cholesteatoma. Although TEES alone could be effective for removal of a cholesteatoma that has progressed to the mastoid antrum, manipulation of the mastoid antrum and reconstruction of the posterior wall of the external auditory canal can sometimes be difficult. Therefore, we combined TEES with percutaneous endoscopic ear surgery (PEES), and used image-guided PEES (IGPEES) using an augmented reality navigation system. Herein, we report a case in which IGPEES was used in combination with TEES for a case of cholesteatoma. The patient was a 69-year-old woman who visited our hospital with the chief complaint of a sense of fullness in her left ear. The patient had stage II pars flaccida cholesteatoma, and CT findings showed that the cholesteatoma had progressed from the tympanic cavity to the mastoid antrum. IGPEES involved making a small skin incision in the retroauricular area, creating a 10-mm window and opening the mastoid antrum, to expose the cholesteatoma. The cholesteatoma in the mastoid antrum was removed to the extent possible, and the epitympanum was opened. The cholesteatoma remaining in the mastoid antrum was pushed towards the external auditory canal via the short crus of the incus. At this point, the modality was switched to TEES and transcanal atticotomy was performed. The cholesteatoma confirmed by PEES was located on the surface of the malleus and incus and could be removed while preserving the ossicular chain. The bone defect size in the lateral wall of the superior tympanic cavity was 6 × 5 mm in size and was reconstructed with cartilage. The surgery took about 170 minutes. The postoperative course was uneventful, and the hearing improved postoperatively. Double keyhole surgery, namely, a combination of TEES with IGPEES, is considered as an ideal minimally invasive procedure that can be applied to treatment of cholesteatoma in any region of the temporal bone.
Kawata et al. (Thu,) studied this question.