®

ENDOSCOPIC EAR SURGERY

Surgical Manual of Standard Procedures

Daniele MARCHIONI, Livio PRESUTTI

and Davide SOLOPERTO
 ENDOSCOPIC EAR SURGERY
Surgical Manual of Standard Procedures

Daniele MARCHIONI1, Livio PRESUTTI2

and Davide SOLOPERTO3

1
| MD, Professor and Head of Department of Otorhinolaryngology,
AOUI Verona, University of Verona, Italy
2
| MD, Professor and Head of ENT Department, University Hospital of
Modena Policlinico, Modena, Italy
3
| MD, Department of Otorhinolaryngology, AOUI Verona, Italy
4 Endoscopic Ear Surgery – Surgical Manual of Standard Procedures

Endoscopic Ear Surgery: Surgical Manual

of Standard Procedures
Daniele Marchioni1, Livio Presutti2
and Davide Soloperto3
1
| MD, Professor and Head of Department of Otorhino-
laryngology, AOUI Verona, University of Verona, Italy
2
| MD, Professor and Head of ENT Department, University
Hospital of Modena Policlinico, Modena, Italy
3
| MD, Department of Otorhinolaryngology, AOUI Verona, Italy

Correspondence address:
Davide Soloperto, MD
ENT Department, AOUI Verona, University of Verona, Italy
P.le A.Stefani 1, 37126 Verona, Italy
E-mail: davidesolop@gmail.com

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Endoscopic Ear Surgery – Surgical Manual of Standard Procedures 5

Table of Contents

1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

2 Middle Ear Anatomical Concepts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

2.1. Retrotympanum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
2.2. Epitympanum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
2.2.1. Epitympanic Diaphragm and Prussak Space . . . . . . . . . . . . . . . . . . . . 11
2.3. Hypotympanum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
2.4. Protympanum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

3 Endoscopic Middle Ear Surgical Procedures and Case Histories . . . . . . . . . . . . . . . . 12

3.1. Endoscopic Myringoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
3.1.1. Rationale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
3.1.2. Endoscopic Myringoplasty with Tragal Cartilage and Perichondrium . . . . 13
Case 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
3.2. Endoscopic Stapedotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
3.2.1. Rationale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
3.2.2. Endoscopic Stapedotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Case 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
3.3. Endoscopic Cholesteatoma Surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
3.3.1. Rationale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
3.3.2. General Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
3.3.3. Attic Cholesteatoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Case 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Case 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
3.3.4. Second-Look Surgery with Ossiculoplasty after Cholesteatoma Removal 22
Case 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

4 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
6 Endoscopic Ear Surgery – Surgical Manual of Standard Procedures

Contributing Authors

Daniele Marchioni,
MD, Professor and Head of Department of Otorhinolaryngology,
AOUI Verona, University of Verona, Italy

Livio Presutti,
MD, Professor and Head of ENT Department,
University Hospital of Modena Policlinico, Modena, Italy

Davide Soloperto,
MD, Department of Otorhinolaryngology,
AOUI Verona, Italy
 Endoscopic Ear Surgery – Surgical Manual of Standard Procedures 7

1 Introduction

The increasingly widespread acceptance of endoscopic sight are visually accessible and it is impossible to “look
techniques emerging in the past decades had – and still around corners”. The straight line of sight, a surgeon
has – a considerable impact on otology, and in particular, typically has to cope with when performing middle ear
on endoscopic surgery of the middle ear. During the surgery through a microscope, is associated with blind
1990s, endoscopy was adopted in otology only as a spots. These limitations can be compensated for by the
diagnostic modality and was never used for surgical complementary use of scopes, that provide a direction
procedures performed via the transtympanic route. of view other than 0 degree (e.g., 30°-scopes).33 Apart
Significant advancements have been made recently in the from a more comprehensive examination of the anatomy,
field of endoscopic-assisted middle ear surgery and have endoscopy allows to explore and better understand
provided the surgeon with an unprecedented, extremely the physiology and ventilation pathways of the middle
detailed view of the “in vivo” anatomy of the middle ear which can become blocked as a result of specific
ear.16, 32, 36 It is generally known that the middle ear is a very pathological alterations.9
small space, which – especially in some of its subunits
– is virtually not amenable to microscopic inspection. While instruments and auxiliary devices used in
The complexity of middle ear anatomy has prompted endoscopic ear surgery are similar to those of traditional
experienced otosurgeons to devise a host of techniques otosurgical procedures, curved instruments have been
for exploring areas that are difficult to visualize with adapted to the current otoscopic approaches – as
the operating microscope. Despite the illumination and determined by principles of good surgical practice –
magnification offered by the operating microscope, its resulting in longer and thinner instruments, with single or
use has proved to be associated with distinct limitations. double curvature, with various angles and more delicate
Only those structures that are located directly in the line of extremities (Figs. 1.1, 1.2).

Fig.|1.1 Left ear. Cadaveric dissection. An ear hook, curved to the left, Fig.|1.2 Right ear. Cadaveric dissection. Double-ended curette used for a
is used to mobilize the chorda tympani in a stenotic external auditory canal. complete exposure of the attic.

a b
Fig.|1.3 Right ear. Panoramic view of the tympanic cavity before (a) and after (b) use of CLARA visualization mode. These specific modes of the digital
image enhancement system is used effectively to brighten dark aspects of the image thus allowing for improved detail recognition.
8 Endoscopic Ear Surgery – Surgical Manual of Standard Procedures

In recent years, major advancements in the field of

videoendoscopic imaging technology have been
introduced in otorhinolaryngology allowing surgeons
to derive particular advantages in terms of real-time
enhanced visualization. An outstanding example of
such an up-to-date high-definition (HD) camera system
is the IMAGE1 S (KARL STORZ Tuttlingen, Germany).
The modular design of the system allow the operator to
choose between various visualization modes (CLARA,
CHROMA and SPECTRA A*/B**), which have been
designed to modify the video signal’s chrominance
components and to improve the perception of details.
Fig.|1.4 SPECTRA B** visualization mode. The visual appearance of The main feature of CLARA mode is that it provides a
vascularity is enhanced and differentiation between the cholesteatoma
matrix and adjacent structures is improved. more distinct appearance of darker areas by harmonizing
density values in all parts of the endoscopic image.
SPECTRA A*/B** mode and CHROMA mode have in
common that they facilitate evaluation of the mucosal
surface and the subepithelial vascularization, and this is
very useful to distinguish healthy tissue from pathology,
especially during cholesteatoma surgery (Figs. 1.3–1.6).

* SPECTRA A : Not for sale in the U.S.

** SPECTRA B : Not for sale in the U.S.

a b c
Fig.|1.5 Tympanic membrane demonstrated by standard visualization (a). Views of the same site using CLARA (b) and CHROMA (c)
image enhancement modes.

a b
Fig.|1.6 Tympanic cavity demonstrated by standard visualization (a) and by use of CHROMA (b) image enhancement mode.
Note the highly vascularized area over the promontory region.
 Endoscopic Ear Surgery – Surgical Manual of Standard Procedures 9

2 Middle Ear Anatomical Concepts

The middle ear can be conceptually divided into 2.1. Retrotympanum

subspaces on the basis of their relationships with the
mesotympanum: the mesotympanum is the portion that The retrotympanum is a complex structure consisting
an observer can visualize through the external ear canal of various spaces located in the posterior aspect of the
by the use of an otoscope or a microscope. Posteriorly tympanic cavity. The retrotympanum is a space divided by
to it lies the retrotympanum, superiorly the epitympanum, a bony crest (termed subiculum) into superior and inferior
anteriorly the protympanum, and inferiorly the hypo- components. The pyramidal eminence is the fulcrum of
tympanum (Fig. 2.1). the retrotympanum (Fig. 2.2). From this structure two bony
structures arise: the chordal ridge and the ponticulus.
The chordal ridge extends outward and transversally
toward the chordal eminence, and separates the facial
recess superiorly and the lateral tympanic sinus inferiorly.
The ponticulus extends inward and transversally to the
promontory region dividing the sinus tympani inferiorly
and the posterior tympanic sinus superiorly.14, 18 The
sinus tympani lies medial to the pyramidal eminence,
the stapedius muscle, and the facial nerve and is located
lateral to the posterior semicircular canal and vestibule.

Fig.|2.1 Right ear. Schematic drawing of the tympanic cavity. Fig.|2.2 Right ear. 45° endoscopic view. The retrotympanum.
Chorda (ct); malleus (ma); incus (in); stapes (s); promontory (pr). Note the pyramidal eminence, the tympanic tract of the facial nerve,
By courtesy of Georg Thieme Verlag KG, Stuttgart, Germany.22 the stapedial region and the round window niche. The cochleariform
process is also visible.
10 Endoscopic Ear Surgery – Surgical Manual of Standard Procedures

Fig.|2.3 Right ear. 45° endoscopic view. Cholesteatoma involving Fig.|2.4 Right ear. 45° endoscopic view after retrotympanic
the superior retrotympanum. Note the extension to the superior cholesteatoma removal. The incus is removed and the tympanic tract
retrotympanum, between the ponticulus superiorly and the subiculum of the facial nerve is clearly identified.
inferiorly. The tegmen and the posterior pillar of round window niche
are covered by cholesteatoma matrix.

The superior limit of this space is represented by the examined the feasibility of gaining endoscopic access
ponticulus. The inferior anatomical boundary is a to this cavity.11,14 The morphology of the sinus tympani
prominent ridge (termed subiculum) that extends from was classified on the basis of intraoperative findings and
the styloid eminence to the posterior rim of the cochlear the anatomical variations of the ponticulus were also
window niche4, 8, 11,18, 29 (Figs. 2.3, 2.4). Recent anatomical described.
studies have been focused on the sinus tympani and

2.2. Epitympanum
The epitympanic space is a pneumatized portion of Depending on the conformation of the cog and tensor
the temporal bone superior to the mesotympanum. tympani fold, the boundary between the AES and the
Various authors have studied the anatomy of the PES can be the cog itself or can be drawn by a coronal
epitympanic compartments. From an anatomical point plane located at the level of the cochleariform process.
of view, it is possible to classify the epitympanum into The body and short process of the incus along with the
two distinct compartments: a larger and posterior one malleus head occupy most of the posterior epitympanic
(posterior epitympanic space, PES) and a smaller and space (Fig. 2.5).
anterior compartment (anterior epitympanic space, AES).

Fig.|2.5 Left ear. Endoscopic cadaveric dissection of the right

epitympanic spaces. Head of the malleus and body of the incus are
clearly visualized. Note the course of the chorda tympani and its
relationship with the ossicular chain.
Endoscopic Ear Surgery – Surgical Manual of Standard Procedures 11

Fig.|2.6 Right ear. The epitympanic diaphragm. The incudomalleolar Fig.|2.7 Left ear. The isthmus. Cochleariform process, malleus and
lateral fold is shown through the 0°-scope. incudostapedial joint are seen endoscopically. The isthmus is checked in
order to remove blockage of the ventilation pathway to the epitympanum.

2.2.1. Epitympanic Diaphragm and Prussak Space

The epitympanic diaphragm consists of three malleal pathways of the epitympanum.19, 20 They observed that
ligamental folds (anterior, lateral, and posterior), the the aeration pathway from the eustachian tube leads
posterior incudal ligamental fold, and two purely directly to the mesotympanic and hypotympanic spaces,
membranous folds (the tensor tympani fold and the whereas the epitympanum is set apart from the direct
lateral incudomalleal fold) together with the malleus and air stream and is only aerated through the tympanic
incus (Fig. 2.6). isthmus. The 0°- and 45°-scopes provide a magnified
view of the space between the incudostapedial joint
Palva and colleagues described the anatomy of the and cochleariform process including the tensor tendon7
epitympanic diaphragm when studying ventilation (Fig. 2.7).

2.3. Hypotympanum
The hypotympanum is part of the tympanic cavity that the hypotympanum corresponds to the juncture of its
lies beneath the level of the eardrum at the junction of outer and inner walls and it separates the tympanic
the tympanic and petrous parts of the temporal bone. It cavity from the jugular bulb. The inferior aspect of the
is usually shaped like an irregular bony groove, extending hypotympanum varies considerably due to the presence
from the finiculus posteriorly toward the eustachian of bony recesses on its floor and its close proximity to the
tube orifice anteriorly (Fig. 2.8). The inferior aspect of inferior retrotympanum24, 25 (Fig. 2.9).

Fig.|2.8 Left ear. Endoscopic cadaveric view of the hypotympanum. Fig.|2.9 Left ear. Inferior retrotympanum and round window chamber.
The finiculus, delineating the posterior boundary of this space, and the The socalled fustis, extending from the styloid complex into round window
eustachian tube orifice anteriorly, are shown. Note the projection of the niche, indicates the position of the round window membrane.
internal carotid artery anteriorly and the bony crests at the level of the
floor of the hypotympanum, corresponding to the jugular bulb projection.
12 Endoscopic Ear Surgery – Surgical Manual of Standard Procedures

Fig.|2.10 Right ear. Endoscopic cadaveric dissection. Protympanic space. Fig.|2.11 Left ear. Endoscopic view of the tubaric orifice and
protympanic cellularity.

2.4. Protympanum
The protympanic space is a pneumatic portion of the surgery, the protympanic space is less important than
middle ear that lies anteriorly to the mesotympanum, other spaces because chronic disease seldom involves
inferiorly to the AES, and superiorly to the hypotympanum26 this recess, however, it is yet noteworthy that some
(Figs. 2.10–2.12). The cochleariform process and the tensor important structures are located there. The protympanum
fold with the tensor tympani canal represent the upper can be divided into two portions: the supratubal recess
limit of the protympanic space, while it is commonly superiorly, and the eustachian tube orifice inferiorly.
bounded posteriorly by the promontory.13 In middle ear

Fig.|2.12 Right ear. Endoscopic aspect of the protympanic region during

cholesteatoma surgery.

Endoscopic Middle Ear Surgical Procedures

3 and Case Histories
3.1. Endoscopic Myringoplasty

3.1.1. Rationale
Although in general microscopic myringoplasty is wide access, which otherwise is fraught with the risk of
considered a safe operation, the endoscopic technique postoperative external auditory canal (EAC) stenosis or
is probably even safer due to the absence of an external anomalous healing processes.
incision, which minimizes the risk of postoperative The direct visualization of the entire medial aspect of the
wound infection or hematoma formation. The procedure middle ear (including the facial nerve) adds support to
obviates the need for bone drilling to create an adequately that concept.1,10
Endoscopic Ear Surgery – Surgical Manual of Standard Procedures 13

3.1.2. Endoscopic Myringoplasty with Tragal Cartilage and Perichondrium

Case 1
Left subtotal eardrum perforation (Figs. 3.1, 3.2). Using a to the anterior edge of the malleus handle. The flap is
0° endoscope, the EAC is infiltrated with a mixture of dissected from the malleus handle using a sickle-shaped
mepivacaine 2% with epinephrine. The edges of the scalpel.
tympanic perforation are debrided circumferentially under
Once the appropriate plane has been developed, the
endoscopic control. The EAC is incised from the 6 o’clock
tympanomeatal flap can be dissected proceeding in a
to the 12 o’clock position. The tympanomeatal flap is
posteroanterior and superoinferior direction, completely
detached from the bone while using cottonoids soaked in
releasing the malleus handle from tympanic residues and
epinephrine (50% with saline solution) to avoid excessive
exposing the anterior annulus (Fig. 3.3).
bleeding. Flap dissection proceeds medially, pushing the
skin medially and anteriorly, encompassing the incision The middle ear is explored to remove any epidermis
until the fibrous annulus is identified. The fibrous annulus fragments that may be present, so as to avoid iatrogenic
is raised with a microhook which offers a good view of the cholesteatoma as well as ventilation patterns (in particular,
middle ear. Dissection of the flap proceeds from posterior isthmus and the tensor tympani fold are also evaluated
to anterior, making sure that the flap remains adherent (Fig. 3.4).

Fig.|3.1 Left ear. Subtotal perforation of the tympanic membrane. Fig.|3.2 Left ear. Magnified aspect of middle ear structures visible
through the perforation. Promontory, protympanic space and stapes
are shown.

Fig.|3.3 Left ear. After cruentation of of the perforation margins, Fig.|3.4 Left ear. Retrotympanic region viewed through the 45°-scope.
the tympanomeatal flap is harvested and detached from the malleus,
clearly exposing the anterior annulus.
14 Endoscopic Ear Surgery – Surgical Manual of Standard Procedures

Fig.|3.5 Left ear. A circumferential island of cartilage is formed as Fig.|3.6 Left ear. The denuded portion of cartilage will be positioned
determined by the eardrum defect. The perichondrial layer on the laterally to the tympanic residues, fitting through the perforation, and the
posterior surface of the cartilage is modeled while maintaining adherence perichondrium will be medial to the tympanic residues and positioned
to the cartilage. A microhook, angled to the left, working length 5.5 cm, under and anteriorly to the malleus handle. The tympanomeatal flap is
is used to insert the graft through the external auditory canal. then repositioned over the graft.

A circumferential island of cartilage is formed as The cartilage graft is finally positioned by passing it above
determined by the eardrum defect. The perichondrial the malleus handle and making contact with the medial
layer on the posterior surface of the cartilage is modeled face of the residual eardrum (Figs. 3.5, 3.6).
making sure that adherence to the cartilage is maintained.

3.2. Endoscopic Stapedotomy

3.2.1. Rationale
Since the introduction of the classic stapedectomy surgeon may choose a close-up view and then swiftly
technique by Shea,28 many different procedures have change to panoramic vision simply by advancing or
been described in the literature from an microscopic withdrawing the scope. Another option is on-axis rotation
point of view.5, 6 The operating microscope provides mag- of the scope in order to obtain a circumferential view. In
nified images of highest quality, however with line of vi- cases of facial prolapse or dehiscence, use of the scope
sion being limited to objects located straight ahead, and can be very helpful in evaluating the stapes footplate
the field of view reaching only the narrowest segment of (platina) and performing stapedotomy in the right position,
the ear canal. The main advantages of the endoscopic eliminating the risk of iatrogenic injury to the facial nerve.
approach are that there is virtually no trauma to the Besides, the endoscopic technique is used effectively
chorda tympani in cases where there is no curetting or in cases of stapes malformation15 or in revision surgery
drilling, and that one has excellent visualization of the where meticulous anatomical scrutiny is needed to better
anterior crus of the stapes, its superstructure, and the understand the real relationship between the surrounding
oval window niche. In the course of the operation, the anatomical structures with the microscope.
Endoscopic Ear Surgery – Surgical Manual of Standard Procedures 15

Fig.|3.7 Left ear. Normal appearence of the tympanic membrane. Fig.|3.8 The skin of the external auditory canal is incised from the
5 o’clock to the 12 o’clock position.

3.2.2. Endoscopic Stapedotomy

Case 2
Left ear (Fig. 3.7). Using a 0°-endoscope, a tympanomeatal better expose the incudostapedial joint. The middle ear is
flap is raised at the wall of the EAC from the 5 o’clock to inspected with a 0°-scope to check the most important
the 12 o’clock position (Figs. 3.8, 3.9). The posterior bony anatomical landmarks (Figs. 3.10–3.12).
part of the EAC may occasionally be curetted or drilled to

Fig.|3.9 Left ear. The tympanomeatal flap is harvested and raised until Fig.|3.10 The stapedial region is exposed. The flap is elevated with
the fibrous annulus is revealed, using a curved otologic dissector, a delicate cupped ear forceps, 1 x 4.5 mm, working length 8 cm.
working length 5.5 cm. Cottonoids saturated with adrenalin solution Occasionally, the posterior bony part of the EAC can be curetted or
facilitate hemostasis during this surgical step. drilled to facilitate exposure of the incudostapedial joint. When curetting
(or drilling) is needed, special care is given to the chorda tympani to
prevent causing iatrogenic damage to this structure.

Fig.|3.11 Left ear. High-definition endoscopic view of incudostapedial Fig.|3.12 Left ear. High-definition endoscopic view of incudostapedial
joint. Stapedial tendon, posterior crus and stapes footplate are clearly joint visualized with a 45°-scope. Note the anterior and posterior crura,
exposed. A micro hook curved to the right is used to confirm the presence stapes footplate and facial nerve which can be appreciated in great detail.
of stapes fixation.
16 Endoscopic Ear Surgery – Surgical Manual of Standard Procedures

Fig.|3.13 Left ear. The stapedial tendon is divided with a curved Fig.|3.14 The stapes superstructure is downfractured with delicate force
microscissors. and removed, leaving the footplate intact. A small drill or a laser may also
be used for this purpose.

Attention is directed at the facial nerve to ensure that it is An endoscopic close-up view of the oval window and
not prolapsed onto the footplate. Following a brief test on the prosthesis offers better control of the final result of
the status of the ossicular chain, the incudostapedial joint surgery. The tympanomeatal flap is repositioned and
is disarticulated sharply in an anteroposterior plane. The sealed with Gelfoam on the external auditory canal
stapedial tendon is divided with small curved scissors (Fig. 3.17).
(Fig. 3.13). The stapes superstructure is downfractured with
delicate force and removed, leaving the footplate intact
(Fig. 3.14). A platinotomy is created at the midportion or
the posterior portion of the footplate with a standard small
drill (Fig. 3.15). A standard teflon or titanium prosthesis
(0.5 mm in diameter and usually 4.75 mm longer ) is
calibrated by measuring the distance from the footplate to
the medial surface of the incus. The prosthesis is placed
between the oval window and the incus. The malleus
is carefully palpated to ensure unimpeded movement
of the ossicles all the way through the prosthesis
(Fig. 3.16).

Fig.|3.15 The platinotomy is performed under endoscopic direct control,

making sure that integrity of the facial nerve is preserved, even in case of
malformations.

Fig.|3.16 The stapes prosthesis is placed between the oval window Fig.|3.17 The tympanomeatal flap is repositioned.
and the incus. Placement of the prosthesis is the most challenging
surgical step because this maneuver is performed with one hand only.
Endoscopic Ear Surgery – Surgical Manual of Standard Procedures 17

3.3. Endoscopic Cholesteatoma Surgery

3.3.1. Rationale
The transmeatal endoscopic approach has shown to be surgical treatment strategy, which should be based on the
a feasible and safe minimally invasive technique for the findings according to the cholesteatoma classification,
exposure and excision of cholesteatoma confined to the differentiating between the following groups:
middle ear cavity and its extensions.17, 34, 35 Improved eradi-
cation of the cholesteatoma by endoscopic removal of 1. Primary acquired cholesteatoma.
hidden pathology from the facial recess, sinus tympani, 2. Secondary acquired cholesteatoma.
anterior epitympanic space, and eustachian tube is one 3. Congenital cholesteatoma.
of the well-accepted benefits of endoscopic ear surgery
(EES)2, 3, 23 (Fig. 3.18).
The pathogenesis of cholesteatoma remains incompletely
Considering that decision-making on the surgical understood. From recent studies with endoscopic
technique to be adopted is largely dependent of the techniques new theories about the genesis of the primary
extent of disease, preoperative otoscopic and radiological acquired cholesteatoma in the attic region can be
findings can play a crucial role in defining an individualized postulated.12, 27, 30, 31

3.3.2. General Indications

The transcanal endoscopic approach enables good
control of the whole tympanic cavity and of the blind areas
(retrotympanum, hypotympanum, and protympanum).
Use of this technique is indicated as first-line treatment
option in patients with congenital cholesteatoma limited
to the tympanic cavity, mesotympanic primary acquired
cholesteatoma with focal retraction of the pars tensa, and
secondary acquired cholesteatoma limited to the middle
ear (Fig. 3.19).

Fig.|3.18 Left middle ear cholesteatoma extending to all spaces of the

tympanic cavity.

a b c d
Fig.|3.19 Schematic drawing showing the range of indications for endoscopic ear surgery (EES) (a–c) as determined by the site of pathology.
The extension of disease into the tympanic cavity is highlighted in glaring red. Limited attic cholesteatoma (a). Cholesteatoma involving the tympanic
cavity without mastoid cell involvement (b). Attic cholesteatoma with extension to the antrum and periantral cells in a patient with a small mastoid
exhibiting a poorly-pneumatized cell system (in this case, a transcanal endoscopic open approach is indicated). Contraindication (d): cholesteatoma
with involvement of the mastoid air cells (in this case, a microscopic approach is required). By courtesy of Georg Thieme Verlag KG, Stuttgart, Germany.22
18 Endoscopic Ear Surgery – Surgical Manual of Standard Procedures

3.3.3. Attic Cholesteatoma

The main goals of the transcanal endoscopic surgical Case 3
approach to attic cholesteatoma removal are:
Attic Cholesteatoma of the Right Ear
: Direct approach to pathology with complete removal
During endoscopic evaluation, an epitympanic perforation
of cholesteatoma. with scutum erosion and attic cholesteatoma is revealed
 Restoration of the ventilation of the upper unit by (Fig. 3.20). The tympanomeatal flap is harvested and
clearing the tympanic isthmus of pathological tissue elevated. Dissection is performed with cottonoids soaked
and mucosal folds that could create a blockage of in epinephrine solution (Fig. 3.21). The flap is elevated using
this important anatomical region, and thus creating a a microdissector, applying traction with the cottonoids
second ventilation pathway by removal of the tensor on the bone surface. Due caution should be exercised
fold. This procedure is aimed at establishing a direct during inferior transposition of the pars flaccida and pars
communication between the anterior attic region and tensa. During this step, the cholesteatoma matrix must be
the protympanum. separated from the eardrum, which is relocated inferiorly
 Preservation of the mastoid mucosa and of the on the long process of the malleus and separated from
transmucosal gas exchange. the umbo (Fig. 3.22). An atticotomy is performed in order
to facilitate exposure of the epitympanic spaces (Fig. 3.23).

Fig.|3.20 Right ear. Transcanal endoscopic approach. The examination Fig.|3.21 Epinephrine solution is injected in the posterior portion of the
reveals an epitympanic cholesteatoma and the mesotympanum is found ear canal. The incision is made clockwise passing from the 3 o’clock to
to be well-pneumatized. the 9 o’clock position, 1.5 to 2 cm from the annulus, using an angled
round knife.

Fig.|3.22 The pars flaccida is accurately dissected from the Fig.|3.23 The cholesteatoma is located laterally with respect to the
cholesteatoma sac, passing from top to bottom. The tympanomeatal ossicular chain. The drum is detached from the umbo.
flap is transposed inferiorly on the malleus.
Endoscopic Ear Surgery – Surgical Manual of Standard Procedures 19

The Prussak space and the ossicular chain are now sure that no residual disease is left behind. Isthmus and
evaluated and particular attention is paid to look for signs tensor fold are evaluated to restore normal ventilation in
of erosion of the chain (Fig. 3.24). If this is not confirmed, case of blockage (Fig. 3.25). Once a tragal incision has
then the standard surgical maneuvers are carried out been made, a piece of cartilage with perichondrium is
carefully in order not to damage this vulnerable structure. used to reconstruct the scutum. The tympanomeatal flap
After complete removal of cholesteatoma, the middle ear is finally repositioned (Figs. 3.26, 3.27).
cavity is thoroughly inspected with a 45°-scope to make

Fig.|3.24 View of the ossicular chain upon complete exposure. Fig.|3.25 Final aspect of the tympanic cavity after cholesteatoma
removal. Careful inspection of the ossicular chain is particularly aimed
at detecting signs of erosion. All spaces of the tympanic cavity are
thoroughly inspected to check for residual disease.

Fig.|3.26 The lateral bony wall of the attic is reconstructed using a tragal Fig.|3.27 The tympanomeatal flap is repositioned and a few Gelfoam
cartilage graft. pledgets are placed in the EAC.
20 Endoscopic Ear Surgery – Surgical Manual of Standard Procedures

Case 4
Congenital Cholesteatoma of the Left Ear
The tympanic membrane is examined with a 0°-otoscope. meatal flap is harvested. The cholesteatoma is found to
A huge cholesteatoma of the middle ear is revealed occupy the entire tympanic cavity (Fig. 3.29). With gentle
(Potsic stage III,21 Fig. 3.28). Following infiltration with a dissection, the cholesteatoma sac is detached from the
topical solution of anestetic and adrenalin, the tympano- mesotympanic and protympanic spaces (Fig. 3.30).

Fig.|3.28 Endoscopic view of the left tympanic membrane. Fig.|3.29 The tympanomeatal flap is completely harvested.
Cholesteatoma is revealed in the mesotympanum. The tympanic cavity is extensively occupied by the cholesteatoma.
Only the long process of malleus is visualized.

Fig.|3.30 The cholesteatoma sac is gently dissected. Fig.|3.31 The cholesteatoma matrix is gradually dissected. The stapes is
found to be eroded, the platina is clearly visualized.
Endoscopic Ear Surgery – Surgical Manual of Standard Procedures 21

Fig.|3.32 The malleus head is transected to expose the medial aspect of Fig.|3.33 The use of angled instruments is critical in removing the
the epytimpanum. Owing to cholesteatoma invasion, the chorda tympani holesteatoma matrix. Note the platina and the course of the facial nerve.
also needs to be transected. The promontory is gradually exposed,
thereby removing the cholesteatoma matrix.

The head of malleus is sectioned and removed in order using a 45°-scope and angled instruments (Fig. 3.34). At
to expose the medial aspect of the epitympanum (Figs. the end of surgery, an ossiculoplasty is performed with
3.31–3.33). The cholesteatoma is completely removed the remodelled head of malleus (Figs. 3.35–3.37).

Fig.|3.34 At the end of surgery, there are no signs of residual disease. Fig.|3.35 Protympanic space and Eustachian tube orifice are free
All sectors are explored with a 45°-scope. of disease.

Fig.|3.36 Ossiculoplasty with the remodelled malleus head is performed Fig.|3.37 Endoscopic view at the end of the surgery. A piece of Gelfoam
to reconstruct the sound-conducting system. Pieces of Gelfoam are is applied to reinforce the attic and the tympanomeatal flap is laid back to
placed around the malleus to provide stable support. return to its anatomical position.
22 Endoscopic Ear Surgery – Surgical Manual of Standard Procedures

3.3.4. Second-Look Surgery with Ossiculoplasty after Cholesteatoma Removal

Case 5
Left ear. After tympanomeatal flap elevation, the tympanic the retrotympanum is free from disease. The stapes is
cavity is exposed through a transcanal endoscopic present and in good condition. After small retroauricolar
approach (Fig. 3.38). The incus is absent, because it has incision, a fragment of cortical mastoid bone is harvested
been eroded by the cholesteatoma and removed during and modeled for ossiculoplasty (Fig. 3.39). A temporalis
previous surgery. Middle ear mucosa is normal, with fascia is also taken. The bone fragment is remodeled and
no evidence of residual cholesteatoma, in particular, placed on the stapes (Fig. 3.40).

Fig.|3.38 Left ear. After tympanomeatal flap elevation, the retrotympanum Fig.|3.39 A mastoid cortical bone fragment is used to reconstruct the
is clearly seen through a transcanal endoscopic approach. Note the ossicular chain.
ponticulus, a bony ridge extending from the pyramidal process to the
promontory region separating the sinus tympani from the posterior
tympanic sinus. The facial nerve and the stapes are clearly demonstrated.

Fig.|3.40 Once the mastoid bone cortical fragment has been,

carved to appropriate size and shape, it is placed under the stapes
making sure that good contact is maintained.
Endoscopic Ear Surgery – Surgical Manual of Standard Procedures 23

Reconstruction is completed placing the temporalis

fascia over the ossiculoplasty and under the drum
(Figs. 3.41–3.43).

Fig.|3.41 The ossicular reconstruction is stabilized with pieces of Fig.|3.42 A temporalis fascia graft is placed over the ossiculoplasty
Gelfoam positioned all around. and beneath the drum.

Fig.|3.43 The tympanomeatal flap is laid back down over the graft
and the ossiculoplasty.
24 Endoscopic Ear Surgery – Surgical Manual of Standard Procedures

4 References

1. AYACHE S, BRACCINI F, FACON F, THOMASSIN JM. 11. MARCHIONI D, ALICANDRI-CIUFELLI M,

Adipose graft: an original option in myringoplasty. PICCININI A, GENOVESE E, PRESUTTI L. Inferior
Otol Neurotol 2003;24(2):158–64. retrotympanum revisited: an endoscopic anatomic
study. Laryngoscope 2010;120(9):1880–6.
2. AYACHE S, TRAMIER B, STRUNSKI V. doi:10.1002/lary.20995.
Otoendoscopy in cholesteatoma surgery of the
middle ear: what benefits can be expected? 12. MARCHIONI D, GRAMMATICA A,
Otol Neurotol 2008;29(8):1085–90. doi:10.1097/ ALICANDRI-CIUFELLI M, AGGAZZOTTI-CAVAZZA E,
MAO.0b013e318188e8d7. GENOVESE E, PRESUTTI L. The contribution
of selective dysventilation to attical middle ear
3. BADR-EL-DINE M. Value of ear endoscopy in pathology. Med Hypotheses 2011;77(1):116–20.
cholesteatoma surgery. Otol Neurotol 2002;23(5): doi:10.1016/j.mehy.2011.03.041.
631–5.
13. MARCHIONI D, MATTIOLI F,
4. DONALDSON JA, ANSON BJ, WARPEHA RL, ALICANDRI-CIUFELLI M, PRESUTTI L. Endoscopic
RENSINK MJ. The surgical anatomy of the sinus approach to tensor fold in patients with attic
tympani. Arch Otolaryngol 1970;91(3):219–27. cholesteatoma. Acta Otolaryngol 2009;129(9):
946–54. doi:10.1080/00016480802468187.
5. KISILEVSKY VE, BAILIE NA, HALIK JJ. Modified
laser-assisted stapedotomy. Laryngoscope 14. MARCHIONI D, MATTIOLI F, ALICANDRI-CIUFELLI M,
2010;120(2):276–9. doi:10.1002/lary.20742. PRESUTTI L. Transcanal endoscopic approach
to the sinus tympani: a clinical report. Otol
6. MAHENDRAN S, HOGG R, ROBINSON JM.
Neurotol 2009;30(6):758–65. doi:10.1097/
To divide or manipulate the chorda tympani
MAO.0b013e3181b0503e.
in stapedotomy. Eur Arch Otorhinolaryngol
2005;262(6):482–7. doi:10.1007/s00405-004-0854-5. 15. MARCHIONI D, SOLOPERTO D, VILLARI D,
TATTI MF, COLLESELLI E, GENOVESE E et al.
7. MARCHIONI D, ALICANDRI-CIUFELLI M,
Stapes malformations: the contribute of the
GRAMMATICA A, MATTIOLI F, GENOVESE E,
endoscopy for diagnosis and surgery. Eur Arch
PRESUTTI L. Lateral endoscopic approach to
Otorhinolaryngol 2016;273(7):1723–9. doi:10.1007/
epitympanic diaphragm and Prussak's space:
s00405-015-3743-1.
a dissection study. Surg Radiol Anat 2010;32(9):
843–52. doi:10.1007/s00276-010-0691-8. 16. MCKENNAN KX. Endoscopic 'second look'
mastoidoscopy to rule out residual epitympanic/
8. MARCHIONI D, ALICANDRI-CIUFELLI M, mastoid cholesteatoma. Laryngoscope
GRAMMATICA A, MATTIOLI F, PRESUTTI L. 1993;103(7):810–4.
Pyramidal eminence and subpyramidal space:
an endoscopic anatomical study. Laryngoscope 17. MIGIROV L, SHAPIRA Y, HOROWITZ Z, WOLF M.
2010;120(3):557–64. doi:10.1002/lary.20748. Exclusive endoscopic ear surgery for acquired
cholesteatoma: preliminary results. Otol
9. MARCHIONI D, ALICANDRI-CIUFELLI M, Neurotol 2011;32(3):433–6. doi:10.1097/
MOLTENI G, ARTIOLI FL, GENOVESE E, MAO.0b013e3182096b39.
PRESUTTI L. Selective epitympanic dysventilation
syndrome. Laryngoscope 2010;120(5):1028–33. 18. OZTURAN O, BAUER CA, MILLER C3, JENKINS HA.
doi:10.1002/lary.20841. Dimensions of the sinus tympani and its surgical
access via a retrofacial approach. Ann Otol Rhinol
10. MARCHIONI D, ALICANDRI-CIUFELLI M, Laryngol 1996;105(10):776–83.
MOLTENI G, GENOVESE E, PRESUTTI L.
Endoscopic tympanoplasty in patients with attic 19. PALVA T, JOHNSSON LG. Epitympanic
retraction pockets. Laryngoscope 2010;120(9): compartment surgical considerations: reevaluation.
1847–55. doi:10.1002/lary.21069. Am J Otol 1995;16(4):505–13.
Endoscopic Ear Surgery – Surgical Manual of Standard Procedures 25

20. PALVA T, RAMSAY H. Incudal folds and epitympanic 28. SHEA JJ Jr. A personal history of stapedectomy.
aeration. Am J Otol 1996;17(5):700–8. Am J Otol 1998;19(5 Suppl):S2-12.

21. POTSIC WP, SAMADI DS, MARSH RR, 29. STEINBRUGGE H. On sinus tympani. Arch
WETMORE RF. A staging system for congenital Otolaryngol. 1889(8):53–7.
cholesteatoma. Arch Otolaryngol Head Neck Surg 30. SUDHOFF H, TOS M. Pathogenesis of attic
2002;128(9):1009–12. cholesteatoma: clinical and immunohistochemical
support for combination of retraction theory and
22. PRESUTTI L, MARCHIONI D. Endoscopic Ear proliferation theory. Am J Otol 2000;21(6):786–92.
Surgery: Principles, Indications, and Techniques.
New York: Thieme; 2014. (ISBN No. 9783131630414). 31. SUDHOFF H, TOS M. Pathogenesis of sinus
cholesteatoma. Eur Arch Otorhinolaryngol
23. PRESUTTI L, MARCHIONI D, MATTIOLI F, VILLARI D, 2007;264(10):1137–43. doi:10.1007/s00405-007-
ALICANDRI-CIUFELLI M. Endoscopic management 0340-y.
of acquired cholesteatoma: our experience.
32. TARABICHI M. Endoscopic management of acquired
J Otolaryngol Head Neck Surg 2008;37(4):481–7.
cholesteatoma. Am J Otol 1997;18(5):544–9.
24. PROCTOR B. Surgical anatomy of the posterior 33. TARABICHI M. Endoscopic middle ear surgery.
tympanum. Ann Otol Rhinol Laryngol Ann Otol Rhinol Laryngol 1999;108(1):39–46.
1969;78(5):1026–40.
34. TARABICHI M. Endoscopic management of
25. PROCTOR B, BOLLOBAS B, NIPARKO JK. Anatomy limited attic cholesteatoma. Laryngoscope
of the round window niche. Ann Otol Rhinol Laryngol 2004;114(7):1157–62. doi:10.1097/00005537-
1986;95(5 Pt 1):444–6. 200407000-00005.
35. TARABICHI M. Transcanal endoscopic management
26. SAVIC D, DJERIC D. Anatomical variations and of cholesteatoma. Otol Neurotol 2010;31(4):580–8.
relations in the medial wall of the bony portion of the doi:10.1097/MAO.0b013e3181db72f8.
eustachian tube. Acta Otolaryngol 1985;99
(5-6):551–6. 36. THOMASSIN JM, KORCHIA D, DORIS JM.
Endoscopic-guided otosurgery in the prevention
27. SEMAAN MT, MEGERIAN CA. The pathophysiology of residual cholesteatomas. Laryngoscope
of cholesteatoma. Otolaryngol Clin North Am 1993;103(8):939–43. doi:10.1288/00005537-
2006;39(6):1143–59. doi:10.1016/j.otc.2006.08.003. 199308000-00021.
26 Endoscopic Ear Surgery – Surgical Manual of Standard Procedures

Instrument Set for Endoscopic Ear Surgery

1 2 3 4 5 6 7

8 9 bl bm bn bo bp

cu

bq br bs bt bu cl cm cn co cp cq cr cs ct dl

dm dn do dp
Endoscopic Ear Surgery – Surgical Manual of Standard Procedures 27

Instrument Set for Endoscopic Ear Surgery

1 227201 Ear Hook, curved right, length 16 cm
2 227202 Same, curved left
3 227203 Same, curved backwards
4 227206 Ear Dissector, curved right, length 16 cm
5 227207 Same, curved left
6 227208 Same, curved backwards
7 227211 Curette, spoon-shaped, diameter 1.0 mm, length 16 cm
8 227213 Curette, double-ended, spoon-shaped tips: diameter 1.0 mm and 1.5 mm, 90° curved, length 17 cm
9 226213 THOMASSIN Dissector, double-ended, distal tips angled 90° to right or left, length 18 cm
bl 226212 Dissector, double-ended, tips double curved right and left, length 18 cm
bm 226211 Same, distal tips with single curve to right or to left
bn 224003 HOUSE Curette, medium, spoon sizes 1 x 1.8 mm and 2 x 3.5 mm, length 15 cm
bo 224004 HOUSE Double Curette, medium, spoon sizes 1 x 1.8 mm and 2 x 2.8 mm, length 18 cm
bp 227230 Round Knife, diameter 3 mm, easy to handle due rotating tube olive, length 19 cm
bq 204359 C Suction Cannula, curved 3 mm, LUER-Lock, outer diameter 1 mm, length 8 cm, conical
br 204361 C Suction Cannula, curved 6 mm, LUER-Lock, outer diameter 1 mm, length 8 cm, conical
bs 204362 C Suction Cannula, curved 6 mm, LUER-Lock, outer diameter 1.2 mm, length 8 cm, conical
bt 204365 C Suction Cannula, curved 8 mm, LUER-Lock, outer diameter 1.2 mm, length 8 cm, conical
bu 204366 C Suction cannula, curved 8 mm, LUER-Lock, outer diameter 1.6 mm, length 8 cm, conical
cl 204367 C Suction Cannula, curved 6 mm, LUER-Lock, outer diameter 1.6 mm, length 8 cm, conical
cm 204357 Suction Cannula, curved 3 mm, LUER-Lock, outer diameter 0.6 mm, length 10 cm
cn 204358 Same, outer diameter 0.8 mm
co 204359 Same, outer diameter 1.0 mm
cp 204360 Suction Cannula, curved 6 mm, LUER-Lock, outer diameter 0.8 mm, length 10 cm
cq 204361 Same, outer diameter 1.0 mm
cr 204362 Same, outer diameter 1.2 mm
cs 204365 Suction Cannula, curved 8 mm, LUER-Lock, outer diameter 1.2 mm, length 10 cm
ct 204366 Same, outer diameter 1.6 mm, length 10 cm
cu 204200 FISCH Suction Handle, with cut-off hole, LUER cone, length 5.5 cm
dl 600019 LUER Cone Connector, male, rotating
dm 227255 Ear Forceps, curved downwards, retrograde, extra delicate, oval cupped jaws, 0.9 mm, working length 10 cm
dn 227253 Same, 45° curved upwards, extra delicate, oval cupped jaws, 0.6 mm
do 227251 Same, 45° curved right
dp 227252 Same, 45° curved left

It is recommended to check the suitability of the product for the intended procedure prior to use.
28 Endoscopic Ear Surgery – Surgical Manual of Standard Procedures

Endoscopic-Guided Middle Ear Diagnosis

Recommended Set according to Dr. M. TARABICHI
HOPKINS® Telescopes and Accessories

1215 AA/BA 1230 AA/BA

1215 AA Tele-Otoscope with HOPKINS® Straight Forward Telescope 0°,

diameter 4 mm, length 6 cm,
autoclavable, fiber optic light transmission incorporated,
color code: green

1215 BA Tele-Otoscope with HOPKINS® Forward-Oblique Telescope 30°,

diameter 4 mm, length 6 cm,
autoclavable, fiber optic light transmission incorporated,
color code: red

1230 AA HOPKINS® Straight Forward Telescope 0°,

diameter 2.7 mm, length 11 cm,
autoclavable, fiber optic light transmission incorporated,
color code: green

1230 BA HOPKINS® Forward-Oblique Telescope 30°,

diameter 2.7 mm, length 11 cm,
autoclavable, fiber optic light transmission incorporated,
color code: red

723773 STAMMBERGER Telescope Handle, round, length 6.5 cm,

for use with HOPKINS® telescopes with diameter 2.7/ 3 mm
and length 11 cm

1218 S Stand, for 3 tele-otoscopes 1215, 1216, 1218,

cartridges with color codes green, red and yellow, autoclavable,
dimensions: 180 x 105 x 80 mm (w x h x d)

203710 Suction Tube, cylindrical, LUER,

outer diameter 1 mm, working length 9 cm
203705
203707
203710
203715

203710
Endoscopic Ear Surgery – Surgical Manual of Standard Procedures 29

LED Battery Light Sources for Endoscopes

11301 D4 11301 DG

11301 D4 LED Battery Light Source for Endoscopes, with fast screw thread,
brightness > 110 lm / > 150 klx, burning time > 120 min,
weight approx. 150 g ready for use, suitable for wipe disinfection

11301 DE Battery Light Source LED for Endoscopes, rechargeable, with click connection,
boost mode for temporary increase in brightness, color temperature 5500 K,
lithium-ion batteries, charging time 60 min, burning time at 100% brightness 40 min,
weight approx. 150 g, suitable for wipe disinfection

11301 DF Battery Light Source LED for Endoscopes, rechargeable, with fast screw thread,
boost mode for temporary increase in brightness, color temperature 5500 K,
lithium-ion batteries, charging time 60 min, burning time at 100% brightness 40 min,
weight approx. 150 g, suitable for wipe disinfection

11301 DG Charging Unit, for 11301 DE/11301 DF, for two LED battery light sources,
with fix integrated power supply and adaptor for EU, UK, USA and Australia,
power supply 110|– 240|VAC, 50/60 Hz, suitable for surface disinfection

094129 Battery Charger Li-Ion, for charging the rechargeable Battery Box 091424
or Battery Light Source 11301 DE/DF, for use with Mains Cord 094127,
power supply 100 – 240 VAC, 50/60 Hz

094127 Mains Cord, for Battery Charger 094129, length 150 cm

30 Endoscopic Ear Surgery – Surgical Manual of Standard Procedures

Endoscopic-Guided Middle Ear Surgery

Recommended Set according to Dr. M. TARABICHI
HOPKINS® Telescopes and Accessories

7230 AA/BA

7220 AA/BA

7230 AA HOPKINS® Straight Forward Telescope 0°,

enlarged view, diameter 4 mm, length 18 cm, autoclavable,
fiber optic light transmission incorporated,
color code: green

7230 BA HOPKINS® Forward-Oblique Telescope 30°,

enlarged view, diameter 4 mm, length 18 cm, autoclavable,
fiber optic light transmission incorporated,
color code: red

7220 AA HOPKINS® Straight Forward Telescope 0°,

enlarged view, diameter 3 mm, length 14 cm, autoclavable,
fiber optic light transmission incorporated,
color code: green

7220 BA HOPKINS® Forward-Oblique Telescope 30°,

enlarged view, diameter 3 mm, length 14 cm, autoclavable,
fiber optic light transmission incorporated,
color code: red

152201 WAGENER Ear Hook, ball end, size 1, length 15.5 cm

152202 Same, size 2
152203 Same, size 3

152301 Ear Hook, without ball end, size 1, length 15.5 cm

152201 152202 152203 152302 Same, size 2

204250 FISCH Adaptor, for Suction Tubes 204352 – 204354,

with long thumb grip, cut-off hole diameter 1 mm,
inner diameter 1.7 mm, LUER cone, length 5.5 cm

204005 Suction Cannula, angular, LUER-Lock,

152301 152302 outer diameter 0.5 mm, working length 6 cm
204007 Same, outer diameter 0.7 mm
204008 Same, outer diameter 0.8 mm
204010 Same, outer diameter 1 mm
204013 Same, outer diameter 1.3 mm
204015 Same, outer diameter 1.5 mm
204020 Same, outer diameter 2 mm
204025 Same, outer diameter 2.5 mm
204005 – 204250 152201 –
204025 152302
Endoscopic Ear Surgery – Surgical Manual of Standard Procedures 31

221100 – 221310

221100 HARTMANN Ear Forceps, extra delicate,

serrated, 1 x 4.5 mm, working length 8 cm
221150 Same, working length 12.5 cm

221210 FISCH Ear Forceps, extra delicate, pointed,

smooth, 1 x 4.5 mm, working length 8 cm

221201 FISCH Ear Forceps, extra delicate,

serrated, 0.4 x 3.5 mm, working length 8 cm

221304 Ear Forceps, extra delicate, serrated,

curved to right, working length 8 cm
221305 Same, curved to left

221307 Same, curved upwards

221310 THOMASSIN Ear Forceps, very fine, serrated,

retrograde backwards curved, working length 8|cm

162500

162500 STRÜMPEL Ear Forceps, working length 8 cm

32 Endoscopic Ear Surgery – Surgical Manual of Standard Procedures

222900

222800 HOUSE-DIETER Malleus Nipper, upbiting,

working length 8|cm
222900 Same, downbiting

221450 – 221454

221454 FISCH Ear Forceps, round cupped jaws,

working length|12.5|cm, diameter 3|mm

221406 – 221709

221509 WULLSTEIN Ear Forceps, extra delicate,

oval cupped jaws, curved to right, oval, 0.9 mm,
working length 8 cm
221609 Same, curved to left

221709 Same, curved upwards

Endoscopic Ear Surgery – Surgical Manual of Standard Procedures 33

222500 – 222605 L

222602 HOUSE-BELLUCCI Scissors, extra delicate,

working length 8 cm

222604 R BELLUCCI Scissors, delicate, curved to right,

working length|8|cm
222605 L Same, curved to left

152301 223100 223500 223890

223101

152301 Ear Hook, without ball end, size 1, length 15.5|cm

223100 PLESTER Knife, round, vertical,

standard size:|3.5 x 2.5|mm, length 16|cm
223101 Same, medium size: 4 x 2 mm

223500 ROSEN Elevator, tip angled 15°, 12|mm long,

width 1.5|mm, length 16|cm

223890 Seeker, extra delicate, angled 25°,

with ball end diameter 0.6 mm, length 16 cm
34 Endoscopic Ear Surgery – Surgical Manual of Standard Procedures

224001 – 224004 224005 224301 – 226211 226212 226213 226815 –

224003 224303 226835

224001 HOUSE Curette, large, spoon sizes 2 x 3.2 mm

and 1.6 x 2.6 mm, length 15 cm
224002 Same, small, spoon sizes 1 x 1.6 mm and 1.3 x 2 mm
224003 Same, medium, spoon sizes 1 x 1.8 mm and 2 x 2.8 mm

224004 HOUSE Double Curette, medium, spoon sizes 1 x 1.8 mm

and 2 x 2.8 mm, length 18 cm

224005 HOUSE Curette, angular, extra small,

spoon sizes 0.6 x 0.8 mm and 0.8 x 1 mm, length 17 cm

224011 HOUSE Curette, straight, extra large,

spoon sizes 2.3 x 3.5 mm and 2.7 x 4.3 mm, length 15 cm

224301 WULLSTEIN Needle, strong long curve, length 16.5|cm

224302 Same, medium curve
224303 Same, slight curve

226211 THOMASSIN Dissector, double-ended,

distal tips with single curve to right or to left, length 18|cm
226212 Same, distal tips with double curve to right or to left

226213 THOMASSIN Dissector, double-ended,

distal tips angled 90° to right or left, length 18 cm

226815 Round Knife 45º, diameter|1.5|mm, length 16|cm

226825 Same, diameter 2.5 mm
226835 Same, diameter 3.5 mm
Endoscopic Ear Surgery – Surgical Manual of Standard Procedures 35

UNIDRIVE® S III ENT SCB/UNIDRIVE® S III ECO

The multifunctional unit for ENT

UNIDRIVE® S III ENT SCB UNIDRIVE® S III ECO

II
III

I
ECO RIVE ® S
ENT RIVE ® S
SCB

UNID
UNID
Special Features:

Touch Screen: Straightforward function selection via touch screen O –

Set values of the last session are stored O O

Optimized user control due to touch screen O –

Choice of user languages O –

Operating elements are single and clear to read due to color display O –

One unit – multifunctional:

– Shaver system for surgery of the paranasal sinuses and anterior skull base
– INTRA Drill Handpieces (40,000 rpm and 80,000 rpm)
– Sinus Shaver O O
– Micro Saw
– Dermatome
– High-Speed Handpieces (60,000 rpm and 100,000 rpm) O –

Two motor outputs: Two motor outputs enable simultaneous connection of two motors:
O O
For example, a shaver and micro motor
Soft start function O –

Textual error messages O –

Integrated irrigation and coolant pump:

– Absolutely homogeneous, micro-processor controlled irrigation rate throughout O O
the entire irrigation range
– Quick and easy connection of the tubing set

Easy program selection via automated motor recognition O O

Continuously adjustable revolution range O O

Maximum number of revolutions and motor torque: Microprocessor-controlled motor rotation
O O
speed. Therefore the preselected parameters are maintained throughout the drilling procedure
Maximum number of revolutions can be preset O O
SCB model with connections to the KARL STORZ Communication Bus
O –
(KARL STORZ-SCB)
Irrigator rod included O –
36 Endoscopic Ear Surgery – Surgical Manual of Standard Procedures

Motor Systems
Specifications

System specifications

Mode Order No. rpm

Shaver mode oscillating

Operation mode: in conjunction with Handpiece:
Max. rev. (rpm): DRILLCUT-X® II Shaver Handpiece 40 7120 50 10,000*
DRILLCUT-X® II N Shaver Handpiece 40 7120 55 10,000*

Sinus burr mode rotating

Operation mode: in conjunction with Handpiece:
Max. rev. (rpm): DRILLCUT-X® II Shaver Handpiece 40 7120 50 12,000
DRILLCUT-X® II N Shaver Handpiece 40 7120 55 12,000

High-speed drilling mode counterclockwise or clockwise

Operation mode: in conjunction with:
Max. rev. (rpm): High-Speed Micro Motor 20 7120 33 60,000/100,000

Drilling mode counterclockwise or clockwise

Operation mode: in conjunction with:
Max. rev. (rpm): micro motor
and connecting cable [ 20 7110 33
20 7111 73 ] 40,000/80,000

Micro saw mode in conjunction with:

Max. rev. (rpm): micro motor
and connecting cable [ 20 7110 33
20 7111 73 ] 15,000/20,000

Dermatome mode in conjunction with:

Max. rev. (rpm): micro motor
and connecting cable [ 20 7110 33
20 7111 73 ] 8,000

Power supply: 100 – 240|VAC, 50/60|Hz

Dimensions: 300 x 165 x 265 mm

(w x h x d)

Two outputs for parallel connection of two motors

Integrated irrigation pump:

Flow: adjustable in 9 steps

* Approx. 4,000 rpm is recommended as this is the most efficient suction/performance ratio.

UNIDRIVE® S III ENT SCB UNIDRIVE® S III ECO

Touch Screen: 6.4" / 300 cd/m2

Weight: 5.2 kg 4.7 kg

Certified to: IEC 601-1 CE acc. to MDD IEC 60601-1

Available languages: English, French, German, numerical codes

Spanish, Italian, Portuguese,|
Greek, Turkish, Polish, Russian
Endoscopic Ear Surgery – Surgical Manual of Standard Procedures 37

Motor Systems
Special features of high-performance EC micro motor II
and of the high-speed micro motor

Special features of high-performance EC micro motor II:

O Self-cooling, brushless high-performance  INTRA coupling enables a wide variety
EC micro motor of applications
O Smallest possible dimensions  Maximum torque 4 Ncm
O Autoclavable  Number of revolutions can be continuously
O Reprocessable in a cleaning machine adjusted up to 40.000 rpm
O Detachable connecting cable  Provided a suitable handle is used, the number
of revolutions can be continuously adjusted up
to 80,000 rpm

20 7110 33

20 7110 33 High-Performance EC Micro Motor II, for use with

UNIDRIVE® II/UNIDRIVE® ENT/OMFS/NEURO/ECO
and Connecting Cable 20 7110 73, or for use with
UNIDRIVE® S III ENT/ECO/NEURO and Connecting
Cable 20 7111 73

20 7111 73 Connecting Cable, to connect High-Performance

EC Micro Motor 20 7110 33 to UNIDRIVE® S III
ENT/ECO/NEURO

Special Features of the high-speed micro motor:

O Brushless high-speed micro motor  Maximum torque 6 Ncm
O Smallest possible dimensions  Number of revolutions can be continuously
O Autoclavable adjusted up to 60.000 rpm
O Reprocessable in a cleaning machine  Provided a suitable handle is used, the number
of revolutions can be continuously adjusted up
O Maximum torque 6 Ncm
to 100,000 rpm

20 7120 33

20 7120 33 High-Speed Micro-Motor, max. speed 60,000 rpm,

including connecting cable, for use with UNIDRIVE® S III
ENT/NEURO
38 Endoscopic Ear Surgery – Surgical Manual of Standard Procedures

UNIDRIVE® S III ENT SCB

UNIDRIVE® S III ECO
Recommended System Configuration

UNIDRIVE® S III ENT SCB UNIDRIVE® S III ECO

40 7016 20-1 40 7014 20

40 7016 01-1 UNIDRIVE® S III ENT SCB, motor control unit with color display,
touch screen, two motor outputs, integrated irrigation pump and
SCB module, power supply 100 – 240 VAC, 50/60 Hz
including:
Mains Cord
Irrigator Rod
Two-Pedal Footswitch, two-stage, with proportional function
Clip Set, for use with silicone tubing set
SCB Connecting Cable, length 100 cm
Single Use Tubing Set*, sterile, package of 3

40 7014 01 UNIDRIVE® S III ECO, motor control unit with two motor outputs and
integrated irrigation pump, power supply 100 – 240 VAC, 50/60 Hz
including:
Mains Cord
Two-Pedal Footswitch, two-stage, with proportional function
Clip Set, for use with silicone tubing set
Single Use Tubing Set*, sterile, package of 3

Specifications:
Touch Screen UNIDRIVE® S III ENT SCB: 6.4"/300 cd/m2 Dimensions w x h x d 300 x 165 x 265 mm
Flow 9 steps Weight 5.2 kg
Power supply 100 – 240 VAC, 50/60 Hz Certified to EC 601-1, CE acc. to MDD

* mtp medical technical promotion gmbh,

take-off GewerbePark 46, 78579 Neuhausen ob Eck/Germany,
Phone: +49 (0) 74 67 9 45 04-0, Fax: +49 (0) 74 67 9 45 04-99,
E-Mail: info@mtp-tut.com, www.mtp-tut.com
Endoscopic Ear Surgery – Surgical Manual of Standard Procedures 39

UNIDRIVE® S III ENT SCB

UNIDRIVE® S III ECO
System Components

Two-Pedal Footswitch Single Use Tubing Set

20 0166 30 031131-10

U N I T S I D E

PATIENT SIDE

High-Speed Micro Motor High-peformance EC Micro Motor II

20 7110 33
20 7120 33 20 7111 73

High-Speed Handpieces INTRA Drill Handpieces Micro Saw Dermatome

252660 – 252692 252575 – 252590 254000 – 254300 253000 – 253300

40 Endoscopic Ear Surgery – Surgical Manual of Standard Procedures

Optional Accessories
for UNIDRIVE® S III ENT SCB and UNIDRIVE® S III ECO

280053 Universal Spray, 6x 500 ml bottles – HAZARDOUS GOODS – UN 1950

including:
Spray Nozzle

280053 C Spray Nozzle, for the reprocessing of INTRA burr handpieces,

for use with Universal Spray 280053 B

031131-10* Tubing Set, for irrigation, for single use, sterile,

package of 10

* mtp medical technical promotion gmbh,

take-off GewerbePark 46, 78579 Neuhausen ob Eck/Germany,
Phone: +49 (0) 74 67 9 45 04-0, Fax: +49 (0) 74 67 9 45 04-99,
E-Mail: info@mtp-tut.com, www.mtp-tut.com
Endoscopic Ear Surgery – Surgical Manual of Standard Procedures 41

INTRA Drill Handpieces

for Ear Micro Surgery

Special Features:
 Tool-free closing and opening of the drill  Lightweight construction
 Right/left rotation  Operates with little vibrations
 Max. rotating speed up to  Low maintenance
40,000 rpm / 80,000 U/min  Reprocessable in a cleaning machine
 Detachable irrigation channels  Safe grip

252570

252573
20 7110 33/20 7111 73

252590

252570 INTRA Drill Handpiece, angled, length 12.5 cm,

transmission 1:1 (40,000 rpm), for use with KARL STORZ
high-performance EC micro motor II and straight shaft burrs
252573 INTRA Drill Handpiece, angled, length 12.5 cm,
transmission 1:2 (80,000 rpm), for use with KARL STORZ
high-performance EC micro motor II and straight shaft burrs
252590 INTRA Drill Handpiece, straight, length 11 cm,
transmission 1:1 (40,000 rpm), for use with KARL STORZ
high-performance EC micro motor II and straight shaft burrs
42 Endoscopic Ear Surgery – Surgical Manual of Standard Procedures

Burrs

Straight Shaft Burrs, length 7 cm,

for use with INTRA Drill Handpieces 252590, 252570, 252573

7 cm

Dia. Tungsten Transverse Diamond,

Detail Size Standard Tungsten Diamond
mm Carbide Carbide coarse

006 0.6 260006 261006 – 262006 –

007 0.7 260007 261007 – 262007 –

008 0.8 260008 261008 – 262008 –

010 1 260010 261010 – 262010 –

014 1.4 260014 261014 261114 262014 –

018 1.8 260018 261018 – 262018 –

023 2.3 260023 261023 261123 262023 262223

027 2.7 260027 261027 – 262027 262227

031 3.1 260031 261031 261131 262031 262231

035 3.5 260035 261035 – 262035 262235

040 4 260040 261040 261140 262040 262240

045 4.5 260045 261045 – 262045 262245

050 5 260050 261050 261150 262050 262250

060 6 260060 261060 261160 262060 262260

070 7 260070 261070 – 262070 262270

260000 Standard Straight Shaft Burr, stainless,

sizes|006 – 070, length|7|cm, set of|15
261000 Tungsten Carbide Straight Shaft Burr, stainless,
sizes|006 – 070, length|7|cm, set of|15
261100 Tungsten Carbide Straight Shaft Burr, with cross cut,
stainless, sizes 014 – 060, length 7|cm, set of 6
262000 Diamond Straight Shaft Burr, stainless,
sizes|006 – 070, length 7|cm, set of|15
262200 Rapid Diamond Straight Shaft Burr, stainless,
with coarse diamond coating for precise drilling
and|abrasion without hand pressure and generating
minimal heat, sizes|023 – 070, length|7|cm, set|of|9,
color code: gold
Endoscopic Ear Surgery – Surgical Manual of Standard Procedures 43

Burrs

Straight Shaft Burrs, length 5.7 cm,

for use with INTRA Drill Handpieces 252590, 252570, 252573

5.7 cm

Dia. Tungsten Transverse Diamond,

Detail Size Standard Tungsten Diamond
mm Carbide Carbide coarse

014 1.4 649614 K 649614 HK 649614 Q 649714 K –

018 1.8 649618 K 649618 HK – 649718 K –

023 2.3 649623 K 649623 HK 649623 Q 649723 K 649723 GK

027 2.7 649627 K 649627 HK – 649727 K 649727 GK

031 3.1 649631 K 649631 HK 649631 Q 649731 K 649731 GK

035 3.5 649635 K 649635 HK – 649735 K 649735 GK

040 4 649640 K 649640 HK 649640 Q 649740 K 649740 GK

045 4.5 649645 K 649645 HK – 649745 K 649745 GK

050 5 649650 K 649650 HK 649650 Q 649750 K 649750 GK

060 6 649660 K 649660 HK 649660 Q 649760 K 649760 GK

070 7 649670 K 649670 HK – 649770 K 649770 GK

649600 K Standard Straight Shaft Burr, stainless, sizes|014 – 070,

length|5.7|cm, set of|11
649600 HK Tungsten Carbide Straight Shaft Burr, stainless, sizes 014 – 070,
length 5.7 cm, set of 11
649700 K Diamond Straight Shaft Burr, stainless, sizes|014 – 070,
length|5.7|cm, set of|11
649700 GK Rapid Diamond Straight Shaft Burr, stainless, with coarse diamond
coating for precise drilling and abrasion without hand pressure and
generating minimal heat, sizes|023 – 070, length 5.7 cm, set of 9,
color code: gold

Straight Shaft Burrs,

cylindrical, barrel-shaped,
and bud-shaped 265050 – 265070

Dia. cylindrical barrel-shaped bud-shaped

Size
mm length 7 cm
020 2 – 262560 –
040 4 – 262561 –
050 5 265050 – 263050
060 6 265060 – 263060
070 7 265070 – 263070
44 Endoscopic Ear Surgery – Surgical Manual of Standard Procedures

Burrs and Accessories

LINDEMANN Burrs, conical, stainless, length 7 cm

Conical
Diameter
Size
mm sterilizable

018 1.8 263518

021 2.1 263521
023 2.3 263523

Burrs Accessories

280090 280080 280120

280090 Size Template, for drills, stainless steel,

sterilizable
280080 Brush, for cleaning atraumatic jaws,
sterilizable, package of 5
280120 Temporal Bone Holder, bowl-shaped,
with 3|fixation screws for tensioning the petrosal
bone and with evacuation tube for irrigation liquid
Endoscopic Ear Surgery – Surgical Manual of Standard Procedures 45

Accessories for Burrs

280030 K

280030

280040
280043

280033
280034

280035

280030 Rack, for 36|straight shaft burrs with a length of 7|cm,

foldable, sterilizable, size 22|x|11.5|x 2|cm
280030 K Metal Bar, for fixation at Rack 280030, to hold 18|burrs
with a length of 7|cm and 16|burrs with a length of 5.7|cm,
size|16|x 2.5|x 1|cm
280033 Rack, for 36|straight shaft burrs with a length of 9.5|cm,
foldable, sterilizable, size 22|x|14|x|2|cm
280034 Rack, for 36 straight shaft burrs with a length of 12.5|cm,
foldable, sterilizable, size 22|x 17|x 2|cm
280035 Rack, for 54 straight shaft burrs with a length of 5 cm
(36 pieces) and 7 cm (18 pieces), foldable, sterilizable,
size 22 x 12.5 x 3 cm
280040 Rack, flat model, to hold 21 straight shaft burrs
with a length of up to 6 cm (6 pcs) and 7 cm (15 pcs),
folding model, sterilizable, size 17.5 x 9.5 x 1.2 cm
280043 Rack, flat model, to hold 21 straight shaft burrs
with a length of 7 cm (6 pcs) and 9.5 cm (15 pcs),
folding model, sterilizable, size 17.5 x 11.5 x 1.2 cm

Please note: The burrs displayed are not included in the rack.
46 Endoscopic Ear Surgery – Surgical Manual of Standard Procedures

Accessories for Burrs

39552 B

Tray for small parts included

39552 A Wire Tray, provides safe storage of accessories for

KARL|STORZ drilling/grinding systems during cleaning
and sterilization, includes tray for small parts,
for use with Rack 280030, rack not included
for storage of:
– Up to 6 drill handpieces
– Connecting cable
– EC micro motor
– Small parts

39552 B Wire Tray, provides safe storage of accessories for

KARL|STORZ drilling/grinding systems during cleaning
and sterilization, includes tray for small parts,
for use with Rack 280030, rack included
for storage of:
– Up to 6 drill handpieces
– Connecting cable
– EC micro motor
– Up to 36 drill bits and burrs
– Small parts

Please note: The instruments displayed are not included in the sterilizing and storage trays.
Endoscopic Ear Surgery – Surgical Manual of Standard Procedures 47

UNIDRIVE® S III ENT SCB

High-Speed Handpieces, angled, 100,000 rpm

For use with High-Speed Drills, shaft diameter 3.17 mm

100,000 rpm
and with High-Speed Micro Motor 20 7120 33
diameter 7.5 mm

20 7120 33

33 mm

7.5 mm
252680

53 mm

7.5 mm
252681

252680 High-Speed Handpiece, short, angled, 100,000 rpm,

for use with High-Speed Micro-Motor 20 7120 33
252681 High-Speed Handpiece, medium, angled, 100,000 rpm,
for use with High-Speed Micro-Motor 20 7120 33
48 Endoscopic Ear Surgery – Surgical Manual of Standard Procedures

UNIDRIVE® S III ENT SCB

High-Speed Handpieces, angled and straight, 60,000 rpm

For use with High-Speed Drills, shaft diameter 2.35 mm

60,000 rpm
and with High-Speed Micro Motor 20 7120 33
diameter 5.5 mm

20 7120 33

31 mm

5.5 mm
252660

51 mm

5.5 mm
252661

31 mm

5.5 mm
252690

51 mm

5.5 mm
252691

252660 High-Speed Handpiece, extra short, angled, 60,000 rpm,

for use with High-Speed Micro-Motor 20 7120 33
252661 High-Speed Handpiece, short, angled, 60,000 rpm,
for use with High-Speed Micro-Motor 20 7120 33
252690 High-Speed Handpiece, extra short, straight, 60,000 rpm,
for use with High-Speed Micro-Motor 20 7120 33
252691 High-Speed Handpiece, short, straight, 60,000 rpm,
for use with High-Speed Micro-Motor 20 7120 33
Endoscopic Ear Surgery – Surgical Manual of Standard Procedures 49

UNIDRIVE® S III ENT SCB

High-Speed Standard Burrs, High-Speed Diamond Burrs

For use with High-Speed Handpieces, 100,000 rpm

100,000 rpm
diameter 7.5 mm

252680 252681

High-Speed Standard Burrs, 100,000 rpm, for single use ,

sterile,|package of 5

Diameter in mm short medium

1 350110 S 350110 M

2 350120 S 350120 M

3 350130 S 350130 M

4 350140 S 350140 M

5 350150 S 350150 M

6 350160 S 350160 M

7 350170 S 350170 M

High-Speed Diamond Burrs, 100,000 rpm, for single use ,

sterile,|package of 5

Diameter in mm short medium

1 350210 S 350210 M

2 350220 S 350220 M

3 350230 S 350230 M

4 350240 S 350240 M

5 350250 S 350250 M

6 350260 S 350260 M

7 350270 S 350270 M
50 Endoscopic Ear Surgery – Surgical Manual of Standard Procedures

UNIDRIVE® S III ENT SCB

High-Speed Diamond Burrs, High-Speed Acorns,
High-Speed Barrel Burrs, High-Speed Neuro Fluted Burr

For use with High-Speed Handpieces, 100,000 rpm

100,000 rpm
diameter 7.5 mm

252680 252681

High-Speed Coarse Diamond Burrs, 100,000 rpm, for single use ,

sterile,|package of 5

Diameter in mm short medium

3 350330 S 350330 M

4 350340 S 350340 M

5 350350 S 350350 M

6 350360 S 350360 M

7 350370 S 350370 M

High-Speed Acorns, 100,000 rpm, for single use ,

sterile,|package of 5

Diameter in mm short medium

7.5 350675 S 350675 M

9 350690 S 350690 M

High-Speed Barrel Burrs, 100,000 rpm, for single use ,

sterile,|package of 5

Diameter in mm short medium

6 350960 S 350960 M

9.1 350991 S 350991 M

High-Speed Neuro Fluted Burr, 100,000 rpm, for single use ,

sterile,|package of 5

Diameter in mm short medium

1.8 350718 S 350718 M

3 350730 S 350730 M
Endoscopic Ear Surgery – Surgical Manual of Standard Procedures 51

UNIDRIVE® S III ENT SCB

High-Speed Standard Burrs, High-Speed Diamond Burrs

For use with High-Speed Handpieces, 60,000 rpm

60,000 rpm
diameter 5.5 mm

252660 252661 252690 252691

High-Speed Standard Burrs, 60,000 rpm, for single use ,

sterile,|package of 5

Diameter in mm extra short short

1 330110 ES 330110 S

2 330120 ES 330120 S

3 330130 ES 330130 S

4 330140 ES 330140 S

5 330150 ES 330150 S

6 330160 ES 330160 S

7 330170 ES 330170 S

High-Speed Diamond Burrs, 60,000 rpm, for single use ,

sterile,|package of 5

Diameter in mm extra short short

0.6 330206 ES 330206 S

1 330210 ES 330210 S

1.5 330215 ES 330215 S

2 330220 ES 330220 S

3 330230 ES 330230 S

4 330240 ES 330240 S

5 330250 ES 330250 S

6 330260 ES 330260 S

7 330270 ES 330270 S
52 Endoscopic Ear Surgery – Surgical Manual of Standard Procedures

UNIDRIVE® S III ENT SCB

High-Speed Diamond Burrs, High-Speed Cylinder Burrs,
LINDEMANN High-Speed Fluted Burrs

For use with High-Speed Handpieces, 60,000 rpm

60,000 rpm
diameter 5.5 mm

252660 252661 252690 252691

High-Speed Coarse Diamond Burrs, 60,000 rpm, for single use ,

sterile,|package of 5

Diameter in mm extra short short

3 330330 ES 330330 S

4 330340 ES 330340 S

5 330350 ES 330350 S

6 330360 ES 330360 S

7 330370 ES 330370 S

High-Speed Cylinder Burrs, 60,000 rpm, for single use ,

sterile,|package of 5

Diameter in mm extra short short

4 330440 ES 330440 S

6 330460 ES 330460 S

LINDEMANN High-Speed Fluted Burrs, 60,000 rpm, for single use ,

sterile,|package of 5

Size in mm
extra short short
(diameter x length)

Diameter 2.1/11 330511 ES 330511 S

Diameter 2.3/26 330526 ES 330526 S

Endoscopic Ear Surgery – Surgical Manual of Standard Procedures 53

Oscillating Micro Saws

254000

254000 Oscillating Micro Saw, inbuilt irrigation tube,

max. recommended number of revolutions 15,000 rpm
corresponds to 15,000 oscillations/min.,
without saw blades, with fork wrench

Saw blades, short shaft, for use with 254000

254024 Saw Blade, short shaft, blade thickness 0.3|mm,

width of blade 6|mm, working length 11|mm,
package of|1, for use with|254000

254025 Same, width of blade 10|mm

254026 Same, width of blade 15|mm

254030 Same, blade thickness 0.15|mm, width of blade 6|mm

Saw blades, long shaft, for use with 254000

254027 Saw Blade, long shaft, blade thickness 0.3|mm,

width of blade 6|mm, working length 26|mm,
package of|1, for use with 254000

254028 Same, width of blade 10|mm

254029 Same, width of blade 15|mm

254031 Same, blade thickness 0.15|mm, width of blade 6|mm

54 Endoscopic Ear Surgery – Surgical Manual of Standard Procedures

Micro Compass Saws, Osseo Scalpel

254100

254100 Micro Sagittal Saw, without saw blades,

integrated irrigation tube, with fork wrench,
recommended maximum speed: 20,000 rpm

Saw blades, for use with 254100

254170 Saw Blade, blade thickness 0.35 mm,

width of blade 4 mm, working length 10 mm,
package of 12, for use with Micro Sagittal Saw 254100
254171 Same, width of blade 6 mm, working length 10|mm

254172 Same, width of blade 6 mm, working length 15|mm

254173 Same, width of blade 10 mm, working length 15|mm

254174 Same, width of blade 12 mm, working length 27|mm

254175 Same, width of blade 6 mm, working length 10|mm

254200

254200 Osseo Scalpel, Micro Saw, with axial/sagittal channel,

pendulum stroke, especially appropriate for 3-dimensional
incision guiding, without saw blades, inbuilt irrigation tube,
max. recommended number of revolution 20,000 rpm,
with fork wrench

Saw blades, for use with 254200

254235 Saw Blade, blade thickness 0.35 mm, working length 12 mm,
package of 12, for use with Osseo Scalpel, Micro Saw 254200

254236 Same, working length 18 mm

254237 Same, working length 24 mm

Endoscopic Ear Surgery – Surgical Manual of Standard Procedures 55

Micro Compass Saws

254300

254300 Micro Compass Saw, without saw blades,

detachable irrigation tube, with fork wrench,
recommended maximum speed: 15,000 rpm

Saw blades, for use with 254300

254312 Saw Blade, blade thickness 0.25|mm,

working length|11|mm, package of 12,
for use with 254300

254313 Same, working length 14|mm

254314 Same, working length 18|mm

254315 Same, working length 22|mm

254316 Same, working length 26|mm

56 Endoscopic Ear Surgery – Surgical Manual of Standard Procedures

Micro Saws – Accessories

39553 A

including basket for small parts

39553 A Sterilizing and Storage Basket, provides safe storage of

accessories for the KARL|STORZ micro saw system during
cleaning and sterilization, includes basket for small parts
for storage of:
– Up to 6 saw handpieces
– Connecting cable
– EC micro motor
– Saw blades
Endoscopic Ear Surgery – Surgical Manual of Standard Procedures 57

Dermatomes

Special features:
 For removing skin and mucosa
 Dermaplaning for obtaining small|pieces|
of skin from behind the ear
 Can be easily adapted to motor
 Optimal setting of the incision depth
 Lightweight construction

253000 Dermatome, with INTRA coupling, width of incision 12|mm,

max. number of rev.|8000|rpm
253001 Replacement Blades, for dermatome 253000,
width of incision|12|mm, non-sterile, package of|10

253100 Dermatome, with INTRA coupling,

width of incision 25|mm, max. number of rev. 8000|rpm
253101 Replacement Blades, for dermatome 253100,
width of incision|25|mm, non-sterile, package of|10

253200 Dermatome, with INTRA coupling,

width of incision 50|mm, max. number of rev. 8000|rpm
253201 Replacement Blades, for dermatome 253200,
width of cut|50|mm, non-sterile, package of|10

253300 Dermatome, with INTRA coupling,

width of incision 75|mm, max. number of rev. 8000|rpm
253301 Replacement Blades, for dermatome 253300,
width of incision|75|mm, non-sterile, package of|10
58 Endoscopic Ear Surgery – Surgical Manual of Standard Procedures

Dermatome – Accessories

39554 A

39554 A Sterilizing and Storage Basket, provides safe storage of

accessories for the KARL|STORZ dermatome system during
cleaning and sterilization
for storage of:
– Up to 2 dermatomes
– Connecting cable
– EC micro motor with INTRA coupling
Endoscopic Ear Surgery – Surgical Manual of Standard Procedures 59

IMAGE1 S Camera System n

Economical and future-proof
 Modular concept for flexible, rigid and  Sustainable investment
3D endoscopy as well as new technologies  Compatible with all light sources
 Forward and backward compatibility with video
endoscopes and FULL HD camera heads

Innovative Design
 Dashboard: Complete overview with intuitive  Automatic light source control
menu guidance  Side-by-side view: Parallel display of standard
 Live menu: User-friendly and customizable image and the Visualization mode
 Intelligent icons: Graphic representation changes  Multiple source control: IMAGE1 S allows
when settings of connected devices or the entire the simultaneous display, processing and
system are adjusted documentation of image information from
two connected image sources, e.g., for hybrid
operations

Dashboard Live menu

Intelligent icons Side-by-side view: Parallel display of standard image and

Visualization mode
60 Endoscopic Ear Surgery – Surgical Manual of Standard Procedures

IMAGE1 S Camera System n

Brilliant Imaging
 Clear and razor-sharp endoscopic images in  Reflection is minimized
FULL HD  Multiple IMAGE1 S technologies for homogeneous
 Natural color rendition illumination, contrast enhancement and color
shifting

FULL HD image CLARA

FULL HD image CHROMA

FULL HD image SPECTRA A *

FULL HD image SPECTRA B **

* SPECTRA A : Not for sale in the U.S.

** SPECTRA B : Not for sale in the U.S.
Endoscopic Ear Surgery – Surgical Manual of Standard Procedures 61

IMAGE1 S Camera System n

TC 200EN

TC 200EN* IMAGE1 S CONNECT, connect module, for use with up to

3 link modules, resolution 1920 x 1080 pixels, with integrated
KARL STORZ-SCB and digital Image Processing Module,
power supply 100 – 120 VAC/200 – 240 VAC, 50/60 Hz
including:
Mains Cord, length 300 cm
DVI-D Connecting Cable, length 300 cm
SCB Connecting Cable, length 100 cm
USB Flash Drive, 32 GB, USB silicone keyboard, with touchpad, US
* Available in the following languages: DE, ES, FR, IT, PT, RU

Specifications:
HD video outputs - 2x DVI-D Power supply 100 – 120 VAC/200 – 240 VAC
- 1x 3G-SDI Power frequency 50/60 Hz
Format signal outputs 1920 x 1080p, 50/60 Hz Protection class I, CF-Defib
LINK video inputs 3x Dimensions w x h x d 305 x 54 x 320 mm
USB interface 4x USB, (2x front, 2x rear) Weight 2.1|kg
SCB interface 2x 6-pin mini-DIN

For use with IMAGE1 S

IMAGE1|S CONNECT Module TC 200EN

TC 300

TC 300 IMAGE1 S H3-LINK, link module, for use with

IMAGE1 FULL HD three-chip camera heads,
power supply 100 – 120 VAC/200 – 240 VAC, 50/60 Hz,
for use with IMAGE1 S CONNECT TC 200EN
including:
Mains Cord, length 300 cm
Link Cable, length 20 cm

Specifications:
Camera System TC 300 (H3-Link)
Supported camera heads/video endoscopes TH 100, TH 101, TH 102, TH|103,|TH|104, TH 106
(fully compatible with IMAGE1 S)
22 2200 55-3, 22 2200 56-3, 22 2200 53-3, 22 2200 60-3, 22 2200 61-3,
22 2200 54-3, 22 2200 85-3
(compatible without IMAGE1 S technologies CLARA, CHROMA, SPECTRA*)
LINK video outputs 1x
Power supply 100 – 120 VAC/200 – 240 VAC
Power frequency 50/60 Hz
Protection class I, CF-Defib
Dimensions w x h x d 305 x 54 x 320 mm
Weight 1.86 kg

* SPECTRA A : Not for sale in the U.S.

** SPECTRA B : Not for sale in the U.S.
62 Endoscopic Ear Surgery – Surgical Manual of Standard Procedures

IMAGE1 S Camera Heads n

For use with IMAGE1 S Camera System
IMAGE1|S CONNECT Module TC 200EN, IMAGE1 S H3-LINK Module TC 300
and with all IMAGE 1 HUB™ HD Camera Control Units

TH 100 IMAGE1 S H3-Z Three-Chip FULL HD Camera Head,

50/60 Hz, IMAGE1 S compatible, progressive scan,
soakable, gas- and plasma-sterilizable, with integrated
Parfocal Zoom Lens, focal length f = 15 – 31 mm (2x),
2 freely programmable camera head buttons,
TH 100 for use with IMAGE1 S and IMAGE 1 HUB™ HD/HD

Specifications:
IMAGE1 FULL HD Camera Heads IMAGE1 S H3-Z
Product no. TH 100
Image sensor 3x 1/3" CCD chip
Dimensions w x h x d 39 x 49 x 114 mm
Weight 270 g
Optical interface integrated Parfocal Zoom Lens,
f = 15 – 31 mm (2x)
Min. sensitivity F 1.4/1.17 Lux
Grip mechanism standard eyepiece adaptor
Cable non-detachable
Cable length 300 cm

TH 104 IMAGE1 S H3-ZA Three-Chip FULL HD Camera Head,

50/60 Hz, IMAGE1 S compatible, autoclavable,
progressive scan, soakable, gas- and plasma-sterilizable,
with integrated Parfocal Zoom Lens, focal length
f = 15 – 31 mm (2x), 2 freely programmable camera head
TH 104 buttons, for use with IMAGE1 S and IMAGE 1 HUB™ HD/HD

Specifications:
IMAGE1 FULL HD Camera Heads IMAGE1 S H3-ZA
Product no. TH 104
Image sensor 3x 1/3" CCD chip
Dimensions w x h x d 39 x 49 x 100 mm
Weight 299 g
Optical interface integrated Parfocal Zoom Lens,
f = 15 – 31 mm (2x)
Min. sensitivity F 1.4/1.17 Lux
Grip mechanism standard eyepiece adaptor
Cable non-detachable
Cable length 300 cm
Endoscopic Ear Surgery – Surgical Manual of Standard Procedures 63

Monitors

9619 NB

9619 NB 19" HD Monitor,

color systems PAL/NTSC, max. screen
resolution 1280 x 1024, image format 4:3,
power supply 100 – 240 VAC, 50/60 Hz,
wall-mounted with VESA 100 adaption,
including:
External 24 VDC Power Supply
Mains Cord

9826 NB

9826 NB 26" FULL HD Monitor,

wall-mounted with VESA 100 adaption,
color systems PAL/NTSC,
max. screen resolution 1920 x 1080,
image format 16:9,
power supply 100 – 240 VAC, 50/60 Hz
including:
External 24 VDC Power Supply
Mains Cord
64 Endoscopic Ear Surgery – Surgical Manual of Standard Procedures

Monitors

KARL STORZ HD and FULL HD Monitors 19" 26"

Wall-mounted with VESA 100 adaption 9619 NB 9826 NB
Inputs:
DVI-D O O
Fibre Optic – –
3G-SDI – O
RGBS (VGA) O O
S-Video O O
Composite/FBAS O O
Outputs:
DVI-D O O
S-Video O –
Composite/FBAS O O
RGBS (VGA) O –
3G-SDI – O
Signal Format Display:
4:3 O O
5:4 O O
16:9 O O
Picture-in-Picture O O
PAL/NTSC compatible O O

Optional accessories:
9826 SF Pedestal, for monitor 9826 NB
9626 SF Pedestal, for monitor 9619 NB

Specifications:
KARL STORZ HD and FULL HD Monitors 19" 26"
Desktop with pedestal optional optional
Product no. 9619 NB 9826 NB
Brightness 200 cd/m2 (type) 500 cd/m2 (type)
Max. viewing angle 178° vertical 178° vertical
Pixel distance 0.29 mm 0.3 mm
Reaction time 5 ms 8 ms
Contrast ratio 700:1 1400:1
Mount 100 mm VESA 100 mm VESA
Weight 7.6 kg 7.7 kg
Rated power 28 W 72 W
Operating conditions 0 – 40°C 5 – 35°C
Storage -20 – 60°C -20 – 60°C
Rel. humidity max. 85% max. 85%
Dimensions w x h x d 469.5 x 416 x 75.5 mm 643 x 396 x 87 mm
Power supply 100 – 240 VAC 100 – 240 VAC
Certified to EN 60601-1, EN 60601-1, UL 60601-1,
protection class IPX0 MDD93/42/EEC,
protection class IPX2
Endoscopic Ear Surgery – Surgical Manual of Standard Procedures 65

Cold Light Fountains and Accessories

495 NT Fiber Optic Light Cable,

with straight connector,
diameter 2.5 mm, length 180 cm
495 NTW Fiber Optic Light Cable,
with 90° deflection to the cold light
fountain on the fountain side,
diameter 2.5 mm, length 180 cm
495 NTX Same, length 230 cm

Cold Light Fountain XENON NOVA® 175

20131501 Cold Light Fountain XENON NOVA® 175,

power supply:
100–125VAC/220–240VAC, 50/60 Hz
including:
Mains Cord
20132026 XENON Spare Lamp,
175 watt, 15 volt

Cold Light Fountain XENON 300 SCB

20 133101-1 Cold Light Fountain XENON 300 SCB

with built-in antifog air-pump, and integrated
KARL STORZ Communication Bus System SCB
power supply:
100 –125 VAC/220 –240 VAC, 50/60 Hz
including:
Mains Cord
SCB Connecting Cord, length 100 cm
20133027 Spare Lamp Module XENON
with heat sink, 300 watt, 15 volt
20133028 XENON Spare Lamp, only,
300 watt, 15 volt
66 Endoscopic Ear Surgery – Surgical Manual of Standard Procedures

Data Management and Documentation

KARL STORZ AIDA® – Exceptional documentation

The name AIDA stands for the comprehensive implementation

of all documentation requirements arising in surgical procedures:
A tailored solution that flexibly adapts to the needs of every
specialty and thereby allows for the greatest degree of
customization.
This customization is achieved in accordance with existing
clinical standards to guarantee a reliable and safe solution.
Proven functionalities merge with the latest trends and
developments in medicine to create a fully new documentation
experience – AIDA.
AIDA seamlessly integrates into existing infrastructures and
exchanges data with other systems using common standard
interfaces.

WD 200-XX* AIDA Documentation System,

for recording still images and videos,
dual channel up to FULL|HD, 2D/3D,
power supply 100 – 240 VAC, 50/60 Hz
including:
USB Silicone Keyboard, with touchpad
ACC Connecting Cable
DVI Connecting Cable, length 200 cm
HDMI-DVI Cable, length 200 cm
Mains Cord, length 300 cm

WD 250-XX* AIDA Documentation System,

for recording still images and videos,
dual channel up to FULL|HD, 2D/3D,
including SmartScreen® (touch|screen),
power supply 100 – 240 VAC, 50/60 Hz
including:
USB Silicone Keyboard, with touchpad
ACC Connecting Cable
DVI Connecting Cable, length 200 cm
HDMI-DVI Cable, length 200 cm
Mains Cord, length 300 cm

*XX Please indicate the relevant country code

(DE, EN, ES, FR, IT, PT, RU) when placing your order.
Endoscopic Ear Surgery – Surgical Manual of Standard Procedures 67

Workflow-oriented use

Patient
Entering patient data has never been this easy. AIDA seamlessly
integrates into the existing infrastructure such as HIS and PACS.
Data can be entered manually or via a DICOM worklist.
All important patient information is just a click away.

Checklist
Central administration and documentation of time-out. The checklist
simplifies the documentation of all critical steps in accordance with
clinical standards. All checklists can be adapted to individual needs
for sustainably increasing patient safety.

Record
High-quality documentation, with still images and videos being
recorded in FULL HD and 3D. The Dual Capture function allows for
the parallel (synchronous or independent) recording of two sources.
All recorded media can be marked for further processing with just
one click.

Edit
With the Edit module, simple adjustments to recorded still images
and videos can be very rapidly completed. Recordings can be quickly
optimized and then directly placed in the report.
In addition, freeze frames can be cut out of videos and edited and
saved. Existing markings from the Record module can be used for
quick selection.

Complete
Completing a procedure has never been easier. AIDA offers a large
selection of storage locations. The data exported to each storage
location can be defined. The Intelligent Export Manager (IEM) then
carries out the export in the background. To prevent data loss,
the system keeps the data until they have been successfully exported.

Reference
All important patient information is always available and easy to access.
Completed procedures including all information, still images, videos,
and the checklist report can be easily retrieved from the Reference module.
68 Endoscopic Ear Surgery – Surgical Manual of Standard Procedures

Equipment Cart

UG 220 Equipment Cart

wide, high, rides on 4 antistatic dual wheels
equipped with locking brakes 3 shelves,
mains switch on top cover,
central beam with integrated electrical subdistributors
with 12 sockets, holder for power supplies,
potential earth connectors and cable winding
on the outside,
Dimensions:
Equipment cart: 830 x 1474 x 730 mm (w x h x d),
shelf: 630 x 510 mm (w x d),
caster diameter: 150 mm
including:
Base module equipment cart, wide
Cover equipment, equipment cart wide
Beam package equipment, equipment cart high
3x Shelf, wide
Drawer unit with lock, wide
2x Equipment rail, long
Camera holder
UG 220

UG 540 Monitor Swifel Arm,

height and side adjustable,
can be turned to the left or the right side,
swivel range 180°, overhang 780 mm,
overhang from centre 1170 mm,
load capacity max. 15 kg,
with monitor fixation VESA 5/100,
for usage with equipment carts UG xxx

UG 540
Endoscopic Ear Surgery – Surgical Manual of Standard Procedures 69

Recommended Accessories for Equipment Cart

UG 310 Isolation Transformer,

200 V – 240 V; 2000 VA with 3 special mains socket,
expulsion fuses, 3 grounding plugs,
dimensions: 330 x 90 x 495 mm (w x h x d),
for usage with equipment carts UG xxx

UG 310

UG 410 Earth Leakage Monitor,

200 V – 240 V, for mounting at equipment cart,
control panel dimensions: 44 x 80 x 29 mm (w x h x d),
for usage with isolation transformer UG 310

UG 410

UG 510 Monitor Holding Arm,

height adjustable, inclinable,
mountable on left or right,
turning radius approx. 320°, overhang 530 mm,
load capacity max. 15 kg,
monitor fixation VESA 75/100,
for usage with equipment carts UG xxx

UG 510
70 Endoscopic Ear Surgery – Surgical Manual of Standard Procedures

Notes:
 with the compliments of
KARL STORZ — ENDOSKOPE