Learning Objectives: This eight minutes narrated surgical video demonstrates the surgical principles of the combined endoscopic and microscopic approach for an extensive epitympanic cholesteatoma with mastoid extension.

Introduction: This narrated video lecture illustrates the indications to utilize a combined technique with transcanal endoscopic atticotomy and microscopic mastoidectomy for cholesteatoma with mastoid antrum extension in a pediatric case.

Methods: A pre-operative endoscopic exam and a CT scan of the temporal bone were obtained for surgical planning. The endoscopic portion of the surgery was performed with rigid 0, 30 and 45 degree endoscopes, 3 mm in diameter and 14 cm in length, connected to a three chip video camera and high definition monitor. A microscopic mastoidectomy was performed to remove disease in the mastoid antrum.

Results: Cholesteatoma was removed in its entirety through a combined endoscopic and microscopic approach. The cholesteatoma extended medially to the ossicular chain and the head of malleus and incus were removed. Ossicular chain reconstruction was performed with autologous incus. The atticotomy defect was reconstructed with a composite graft of conchal cartilage and perichondrium. The patient was free of disease at second look transcanal endoscopic surgery with excellent hearing result.

Conclusions: Endoscopic ear surgery offers wide field visualization of the attic space and the mastoid antrum. When cholesteatoma has extension into the mastoid space posteriorly to the point of reach of the endoscopic technique, a microscopic mastoidectomy is required for complete eradication of mastoid disease. This surgical case demonstrates how the endoscopic and microscopic surgical approach to cholesteatomas are not exclusive of each other but they can be utilized in combination to fully visualize and remove extensive disease.