Endoscopic Reverse Stapedotomy Professional Surgery Video

Endoscopic Reverse Stapedotomy: Good day, everyone. I’m Dr. Akbar Abbas and today, we’ll be walking through a complex case of endoscopic reverse iDOT. As you observe, we begin with the incision at the 12 o’clock position using a Plester knife, followed by an additional incision at 6 o’clock. These incisions will be connected circumferentially with the help of a Rosen knife. It’s crucial to ensure that an adequate length of the flap is maintained, which will later cover the defect once the bone is removed.

Using cotton pledgets can be highly effective here. These not only help in lifting the flap from the bone but also absorb blood, providing a clearer field of vision. As we elevate the flap, you’ll see that the corda tympani is now identified. We will gently elevate it from its bed, following its path with a sharp instrument to gain better access.

With the corda tympani out of the way, we can start curating the bony overhang. This step reveals the incudomalleolar joint and the round window. Notice the direction of the curette—it’s important to use your middle finger as a fulcrum, guiding the curette from inside out and from top to bottom, much like scooping ice cream from a bowl. A drill may be necessary, but a skilled hand with a curette often suffices.

As we proceed, you can see the facial nerve emerging behind the incus, as well as the posterior crus of the stapes. The stapedius muscle and the footplate come into view, and here’s a key point: don’t hesitate to remove extra bone for better access to the footplate. Remember, this extra bone will be covered later by the tympanic membrane and the elevated flap.

We’ll now confirm the diagnosis of stapes fixation by checking the mobility of the incus and malleus. With the diagnosis confirmed, we’ll use a straight pick to make a precise puncture in the posterior part of the footplate. This is a delicate process, requiring just a gentle pressure to perforate the footplate.

Now that the perforation is made, we’ll use a rasp to slightly widen the opening, just enough to accommodate the 3 mm Teflon piston we’re using today. Although we typically use a 4 mm piston, the 3 mm was available, and it will suffice for this procedure.

We’ll carefully lower the prosthesis onto the long process of the incus using a suction tip for better control. It’s crucial to ensure the lower part of the prosthesis is securely seated in the vestibule. After placing the piston, we disarticulate the suprastructure of the stapes from the incus using a straight pick, ensuring that the incus remains stable without subluxation.

Finally, we’ll remove the suprastructure and confirm the placement of the piston in the vestibule with a mobility test and the bending test. The slight bend in the piston indicates correct positioning, ensuring it’s secure and functional. We’ll now reposition the tympanic membrane and flap, supporting it with gel foam. No antibiotic-soaked dressings are necessary in this case, as the gel foam alone will suffice.

This concludes our reverse stapedotomy procedure. Thank you for joining us in this step-by-step walkthrough.

This educational video allows students and patients to make informed decisions about their own and others’ health. Dr Akbar Abbas is a leading figure in ENT surgery within Pakistan, offering hope and expertise to countless patients facing similar challenges. He specializes in otolaryngology, cochlear implants, and ear surgery and is one of the few experts on pituitary and head and neck cancer surgery in Pakistan. He is presently serving at Aga Khan University.