LAUSR

We reviewed the paper entitled ‘‘Comparison of endoscopic and microscopic tympanoplasty’’ by Kuo et al. [1]. This is an excellent work, in which the authors compared the healing outcomes and hearing improvements between patients treated via endoscopic or microscopic tympanoplasty with or without ossiculoplasty or mastoidectomy. Previous studies have focused only on the outcomes of endoscopic myringoplasty or type I tympanoplasty [2–4]. The authors show that endoscopic tympanoplasty is a feasible form of middle-ear surgery. The success rates, audiometric improvements, and complication rates of endoscopic tympanoplasty and conventional microscopic tympanoplasty were comparable. Moreover, the endoscopic group required smaller incisions and their medical costs were lower. Although endoscopic ear surgery affords many advantages, endoscopy has not yet been widely embraced by otologists and the long-term outcomes require further attention. Some studies reported that endoscopy was associated with longer operating times. Many surgeons are uncomfortable when operating one-handed and viewing a two-dimensional image with no depth-of-field. Indications for middle-ear surgery performed with the aid of endoscopy alone must be further investigated. The authors write: ‘‘The procedures included tympanoplasty with or without ossiculoplasty or mastoidectomy. The endoscopic group underwent tympanoplasty under general or local anesthesia, which was performed by the same surgeon, and the position of these patients was the same as that in routine otomicroscopic ear surgeries. A full endoscopic transcanal approach was performed with rigid endoscopes with a 3-mm diameter, a 14-cm length, and angles of view of 0 and 30. The microscope group underwent tympanoplasty all under general anesthesia with the surgical technique of endaural or retroauricular approach. The material of graft in the both groups was temporalis fascia’’ [1]. An endoscope affords a wide surgical field and allows the middle-ear structure to be well-visualized, even through a narrow external auditory canal. In addition, a retroauricular approach is not necessary [5, 6], thereby reducing the operative time of some middle-ear surgeries. However, the lack of a third dimension and the need to operate one-handed may prolong the operative time of some middle-ear surgeries. During ossiculoplasty, use of an endoscope is more difficult than employment of a microscope when perfect ossicular chain reconstruction is required; stability is compromised when operating onehandedly. During mastoidectomy, the surgeon holds the endoscope in one hand and an electric drill in the other; it is difficult to meticulously control mastoid bone drilling because the nearby facial nerve is susceptible to damage. This concern prolongs the mastoidectomy time and increases the complication rate. In addition, the tip of the endoscope can become contaminated by blood (if bleeding develops), obscuring the operative field. Continuous water washing and hemostasis (using epinephrine-soaked cotton) This comment refers to the article available at doi:10.1007/s00405017-4570-3.