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Hearing Basics

Hearing loss comprises reduced sensitivity for pure tones (the audiogram) and problems in the understanding of speech. The loss of sensitivity results from deficits in the transmission of sound via the middle ear and/or loss of transduction of mechanical vibrations into electrical nerve activity in the inner ear. Problems of speech understanding mainly result from deficits in the synchronization of auditory nerve fibers’ (ANFs) and central…

Exoscope application in free flap head and neck reconstruction

12.1 Introduction of 3D exoscopes in reconstructive microsurgery Exoscopic technology was first introduced in free flap reconstruction in 2017. In particular, Piatkowski et al. described their experience in breast reconstruction with a bilateral deep inferior epigastric perforator flap. The authors highlighted the lower depth of field compared to the operating microscope and the loss of resolution of the image at higher magnification. However, they believed in the…

Exoscope-assisted thyroid surgery

11.1 Technological advancements in thyroid and parathyroid surgery At the beginning of the 21st century, technological advancements in thyroid and parathyroid surgery served to obtain better cosmetics results and lower postoperative pain. Minimally invasive video-assisted parathyroidectomy and thyroidectomy relied on the use of an endoscope. , A further upgrade was obtained by adding a three-dimensional (3D) view of the surgical field. More recent techniques, including thyroidectomy…

3D exoscopic parotidectomy

10.1 Introduction Benign parotid tumors have historically been treated by parotidectomy focused on the complete resection of the neoplasm with facial nerve preservation. Parotid masses were formerly managed via surgical enucleation, as first described by Béclard in 1824 with the aim of avoiding any facial nerve damage. , Nonetheless, tumor recurrence was pointed out in the mid-50s as the main risk of enucleation. Since then, several…

The application of the exoscope in lacrimal surgery

9.1 Introduction 9.1.1 Anatomy and physiology of the lacrimal drainage apparatus The lacrimal drainage apparatus is a system that carries tears, produced by the lacrimal gland, from the ocular surface to the nasal cavity. It is defined by the following structures: the puncta, the canaliculi, the lacrimal sac, and the nasolacrimal duct. Moreover, two one-way valves are physiologically important to prevent tear reflux: the valve of…

Exoscopic surgery of lateral skull base

8.1 Introduction Literature includes some studies about the use of an exoscope in neurosurgery, either as an exclusive instrument or in combination with the microscope. The use of the operative exoscope has recently been introduced in head and neck surgery, and there are only a few studies in the literature regarding this kind of exoscopic surgery. Lateral skull-base surgery is traditionally performed mainly using the operative…

Exoscope-assisted middle ear surgery

7.1 Historical background In ear surgery, optical magnification and stereopsis are essential in identifying anatomical structures and performing surgical procedures safely and successfully. The need for stereopsis and the importance of three-dimensional perception of the complex anatomy of the ear during surgery was firstly recognized 150 years ago, in 1869, by the Italian Emilio De Rossi. This concept was brought to clinical practice approximately 50 years…

Exoscope-assisted oropharyngeal surgery

6.1 Introduction The oropharynx is currently one of the most affected sites in head and neck oncology. Over the past 20 years, the incidence of oropharyngeal cancer has increased significantly, especially in younger people. This trend is clearly related to previous human papillomavirus infection. For advanced-stage oropharyngeal cancer, treatment generally includes at least two therapeutic modalities (surgery followed by radiation therapy or concurrent chemoradiotherapy), whereas for…

Exoscope-assisted submandibular salivary stones surgery

5.1 Historical background Salivary stones were extracted as far as before Renascence, as well as abscesses and ranulas. With corpse dissection from the mid-17th century, the increasing anatomic and functional knowledge allowed to broaden surgical techniques. In 1656, Thomas Wharton was the first to describe the submandibular duct, in his paper “Adenographia,” in which he described also the anatomy and function of salivary glands. In the…

Exoscope-assisted laser laryngeal surgery

4.1 The exoscope in transoral laryngeal surgery 4.1.1 Background The recent development of exoscopic systems was first aimed for surgical recording and teaching purposes. Then, the implementation with 3D cameras, 4K resolution, and ergonomic holders have driven increasing interest in their application for direct surgical view. In the head and neck field, several applications have been tested, including otosurgery, otoneurosurgery, microvascular anastomosis, and transoral oropharyngeal surgery.…

Exoscope-assisted microlaryngeal surgery

3.1 The introduction of exoscopes in microlaryngeal surgery The use of the operating microscope in laryngology was first introduced in 1960 by Scalco, Shipman, and Tabb in New Orleans, United States. In their work, they described the applicability of a Zeiss binocular microscope, designed for otologic surgery, with the Lynch suspension laryngoscope to treat small, benign lesions, confined to the true vocal folds. However, it is…

Educational role and preclinical application of exoscope-assisted surgery

2.1 Role and importance of education in microsurgery Microsurgery was first introduced in the otolaryngology field at the beginning of the 900s. In 1921, a monocular microscope with a high magnification was first used in ear surgery for the need of a surgical field magnification for the visualization of restricted areas. This introduction required proper training of surgeons to work in a different way, with a…

Exoscopic technology

1.1 Introduction Microsurgical procedures have been developed during the last decades in several specialties. The operating microscope was indeed extensively used to perform fine and delicate surgeries in many fields. In particular, ENT surgeons usually perform ear, microlaryngeal, and skull base surgery with the operating microscope in daily surgical activity. Moreover, head and neck free flap reconstruction is now widespread in many ENT centers. The technological…

Neuromonitoring in Endoscopic Skull Base Surgery

Introduction Endoscopic surgery of the cranial base is frequently utilized for pathologies such as pituitary adenoma, craniopharyngioma, chordoma, and chondrosarcoma. Such operations involve working in close proximity to critical neurovascular structures. Insult to these vital structures can result in postoperative neurological deficits that drastically impact the patient’s quality of life. It becomes imperative for the neurosurgeon to not only perform optimum resection of the lesion but…

Complications in Endoscopic Skull Base Surgery

With continued advancements in endoscopic approaches for skull base surgery, understanding the risks and potential complications of these techniques is critical in planning surgical access and counseling patients. Extensive transclival operations, coronal plan approaches lateral to the carotid artery, and endoscopic orbital approaches have allowed more lesions to be accessed through less-invasive approaches. But each of these techniques is associated with an evolving risk profile. We…

Transorbital Endoscopic and Neuroendoscopic Surgery

The development of transnasal endoscopic approaches to skull base pathology significantly decreased the surgical disruption and collateral damage relative to their open predecessors, such as the craniofacial and subcranial approaches. In addition, the improved illumination, magnification, and visualization on a high-quality monitor afforded by endoscopes provided surgeons with major technologic improvements. Although transnasal approaches are the most common endoscopic pathways in use today, drawbacks to these…

Reconstructive Techniques in Endoscopic Skull Base and Orbital Surgery

Advances in endoscopic surgical techniques and instrumentation have led to an expansion in the size and diversity of skull base lesions that are amenable to endoscopic resection. However, one of the stipulations for adopting an endoscopic approach for the removal of skull base lesions is the ability to repair the resultant defect, as failed reconstructions, and the subsequent cerebrospinal fluid (CSF) leak, add significant morbidity. With…

Endoscopic Endonasal Approaches to the Optic Apparatus: Technique and Pathology

The optic apparatus includes the optic nerves, chiasm, and optic tracts. Lesions affecting this region vary widely with respect to histologic type, site, extent, and clinicopathologic behavior. Treatment of these lesions therefore requires a comprehensive multidisciplinary approach with a team consisting of skull base neurosurgeons, otolaryngologists, and ophthalmologists, as well as radiation and medical oncologists. Although observation and radiotherapy may play important roles, surgical treatment represents…

Transcranial Approaches to the Optic Apparatus

Transcranial approaches to the optic apparatus include both traditional approaches, such as frontotemporal (pterional) and bifrontal craniotomies, as well as more recent minimally invasive keyhole approaches, including the supraorbital eyebrow approach and minipterional approach. Given advances in understanding anatomy, instrumentation, and, perhaps most importantly, the addition of high-definition endoscopy, the use of these smaller, minimally invasive approaches is becoming increasingly incorporated into routine neurosurgical practice at…

Surgical Anatomy of the Optic Nerves and Chiasm

The optic nerve and chiasm can be involved with pathology affecting the orbit, orbital apex, and skull base. When surgically addressing these structures, it is critical to maintain not only their neural integrity but also their vascular supply, as this will allow for superior visual outcomes. Even relatively common procedures such as endoscopic endonasal transsellar resections of pituitary adenomas require a robust surgical knowledge of the…