Learning Objectives:

Introduction: Totally endoscopic ear surgery (TEES) facilitates cholesteatoma treatment giving enhanced visulation of middle ear recesses without the post-operative morbidity of open surgery. TEES is not as yet an acceptable option for all cases, or indeed all surgeons. This study reports on factors influencing the adoption of TEES in paediatric cholesteatoma by a single surgeon.

Methods: A paediatric cholesteatoma surgery database, maintained over an 11 year period, was searched to determine the proportion of cases completed by TEES or an open post-auricular approach each year. Comparison was made with factors potentially linked to the surgeon's ability to perform TEES including extent of cholesteatoma, patient age, availablity of equipment and attendance at endoscopic courses.

Results: Of 649 surgeries 86 were by TEES and 37 by endoscope transcanal with microscope-guided assistance. The proportion of TEES cases per year increased from 1/75 (1%) to 35/57 (61%) over the last 7 years. Empirically, this increase correlated with acquistion of specialised instruments and attendance at courses. Overall, TEES cases were less extensive (median Mills stage: 1 versus 2; p < 0.001, MannWhitney) but similar in age (median 11.5 v 10.8 yr NS, MannWhitney). Over the last 50 open cases, extent of disease (54%), narrow ear canal (30%) and defect too large for reconstruction (12%) were noted as the commonest factors for utilising an open approach. Most recently, endoscopic canalplasty and non-autogenous grafts have further increased the range of TEES.

Conclusions: Cholesteatoma can be treated in a majority of children with TEES, but an open approach is still required when the ear canal provides inadequate access to the limits of the disease. The surgeon's ability to complete TEES is enhanced by appropriate training, acquistion of specialist instruments, motivation and experience. Development of surgical techniques is allowing a greater proportion of cases to be completed endoscopically.