So for these endoscopic cases, what we like to do is inject off the field first. A couple of reasons for that: one is that it allows us to inject the anesthetic under the microscope rather than under the endoscope, which is what we're typically used to in these cases. What it also does is it sort of forces us to allow enough time for the local anesthetic to work. And so, that's what we'll do. We prepare our own mixture of local anesthetic in these cases as well. We mix 0.1 cc of 1:1000 epinephrine with 1% lidocaine, with epinephrine 1:100,000, 3 cc of that. And that gets us a concentration of approximately 1:35,000 epinephrine. Our injection is otherwise our standard injection. So we're going to perform this just lateral to the bony cartilaginous junction here. And just inject very slowly. And we're starting to see that blanching there. You can see just medial to the bony cartilaginous junction, that area of skin that was pink before is starting to kind of turn that nice - that nice pink, or excuse me, that nice white. She's breathing a little heavy. Yeah, I see that she's (indistinct). I'm going to give her a little propofol to make her calm down. Okay. But I see what you're talking about. So again, with this injection, we're really just taking our time. A lot of times it doesn't feel like you're even injecting anything, but you can see the frosting there on the tip of the needle, which is indicative that there is flow through that. And again, when you're doing an endoscopic case, hemostasis from your injection is absolutely critical because you're often losing one hand. And again, I mentioned that we're using a concentration of epinephrine that's more concentrated than what we typically use. And so patient selection is pretty critical there as well. If you have a patient with underlying cardiac conditions or an older patient, you know, it may not be somebody that you want to select for an endoscopic case. Or just being prepared to not have as good of an injection performed. And again, the patience here in these 5-10 minutes getting your case set up go a long way for the rest of the case. That propofol helped settle her out. I don't know if you've already given it to her or not. So we've done a posterior injection, a superior injection, and then we're going to do one last inferior injection here. And then as we prep her thereafter, that allows at least 10 minutes for the local anesthetic to start doing its thing. And again, we can see that nice blanching that's occurring there, and as these 10 minutes go on, that blanching will work its way medially as well.
Can I see just a regular 3 suction first? All right so, obviously we've allowed ample time for our local to work. Hopefully it hasn't worn off at this point. You know, there are certainly options where you can inject on the field as well. And then in order to do things to delay and set your time aside, you can trim the ear hair. In this case, we are, our patient doesn't have much in the first place so not really something we're concerned about. That's good for now. Did you get the 0-degree? Yeah, he got it. (indistinct). All right. I'll take the irrigation myself now, please. And the suction, please. Thank you. So you can make some different, kind of more creative flaps when you do these endoscopic cases, some that are a little bit more minimal than your standard tympanomeatal flap or Rosen flap. You know, in a 50-year-old female, it looks like she's got good skin, and it's nice and thick, but I think we'll still for the purposes of this, just do a standard tympanomeatal flap for our incisions. Can I see the sickle knife now Paulo? Stay with me. Stay with me, Paulo, stay with me. All right. So similarly, if we were going to do this under the… Let me reclamp this. That's the reason I have this here and kind of like straight up on this rather than like away or wherever else, is it allows you to kind of just come straight out. Like, you're not having to pull away very much whenever you're doing that. Nice. All right. So we're going to stick with the 0-degree endoscope for the time being. And for our inferior cut, we're going to come down, pretty much kind of the same way we do our other ones, around the 5, 6 o'clock position, all the way down to the annulus. Come down into the bone. Come lateral with our cut. Go back in the same spot. Lateral with the cut. And you can see we've gotten very good hemostasis from our injection. And similarly, if we were working under a microscope, I always like to make this inferior cut rather than the superior cut, because that way you don't have something bleeding down while you're trying to make the other incision. So now we're going to transition up into our superior cut here. You can see the lateral - I guess just for some landmarks here, you can see… Real quick… You can see our eardrum is here, our long process of the malleus, the umbo here, the lateral process, and then the pars flaccida up here, pars tensa down here. And so for this one, I like to make it, you know, good and superior in case we need to address anything like malleus fixation or the like, and allows us to get our flap turned very anteriorly. So we're going to start at about the 12 o'clock position. And again, bring this out laterally, about 4-5 mm. And again, all the way down to bone on those cuts, right? You don't want that flap tearing as we're elevating it. Okay? I'll take a regular round knife now, please, Paulo. We don't happen to have the 7200 Beaver blade, do we? I'll take a 72, please. Okay, the 7200? Can you get me a little bit of support on that? The 72. The 7200 Beaver. It's pretty accessible, right? Thank you. So this is basically like a bigger round knife, but it's disposable so it's always really sharp. Okay. And it allows you to make like a nice clean cut with it. Okay. You know, with the round knife, obviously, I think we could still get a good one, but again, for the sake of it, we may as well try it. That's good. All right. So again, you can see this instrument kind of looks a little bit like a round knife, but it's a curved blade. And again, this is disposable so we know it's going to be sharp when we use it. And it's just going to allow us to then kind of make this lateral incision here. Which we've now got… All right Paulo, I'm going to switch to just the regular round knife for a moment, okay? Thank you. All right, so now that we've got our incisions made, we're going to - you know, we have some suction round knife and some other suction instruments, which are great to use, but I always like to kind of get this first part just gently started with the non-suction instruments so that we don't suction on the lateral aspect of the flap too much. You know, I'm just kind of gently feeling where the bone is there and getting that flap elevated. Getting this skin up superiorly, and the area of the vascular strip between the tympanomastoid and tympanosquamous suture lines is going to be much thicker, and you can see that, as we're pushing here, that that's the case. All right Paulo, let's see that suction round knife now, please. Now we can confirm that we're elevating the flap off of the bone here. I'm going to work in kind of this wide plane. Try not to get ourselves dug into any holes. You can see some of these adhesions here. Superiorly, you know, the cut - we always try to get it down and pull through the bone but that's not always the case. So sometimes I'll kind of elevate underneath in the vascular strip flap to allow that to tent up, and then we'll come back with a sharp scissor to get that area. And sometimes kind of dropping the hand will allow the suction to work there a little bit. I don't know if it's going to get us all the way down. We can see that that flap is now elevated there. Push that forward as we go. Then come back to our superior aspect over here. See if that's not all the way through - it's close. Paulo, can I see the Bellucci scissors, please? Thank you. So again, you're going to elevate medially just inferior to that little portion right there that's tethered. And then that will allow you to get like a Bellucci scissors in, one on each side, and just kind of complete that initial skin incision. Okay. I'll go back to that suction round knife again, please. Thank you. Now that incision is completed. And we can finish elevating the whole flap down to the level of the annulus. We're getting very close there. Starting to feel that bone kind of slip away. So roll that forward.
You can start to feel that groove right here. So as we do that, we're going to kind of just gently elevate and push, and you can see the annulus there. But rather than using the suction round knife for that, Paulo, do you have the suction Rosen that we can switch to? It's kind of like a needle. Yeah, yeah. Maybe not perfect for that, but still comparable. Do you have the 3 suction in the meantime? You got that ready? You can see that color change there. Right? You see the white band right there? That's the annulus coming out of the groove, and then that thinner middle ear mucosa on the other side. So I can just kind of elevate and come through that with this needle, which you can see happening there. So we get in, we're going to kind of push. Okay. And now, can I see the Gimmick please? So once you've got enough of an exposure of that middle ear mucosa open, you can switch over to a Gimmick inferiorly. And again, just kind of place it underneath. And the annulus along with, as long as your tympanomeatal flap has been elevated medially enough there, you can just elevate that whole annulus out of the groove there. And now we're going to do a little den doorstop and take a Gelfoam with epinephrine please. And what this is going to do is allow us to gently slide this piece of Gelfoam with epinephrine here. There's often a vessel that comes in inferiorly on the tympanic membrane. So that can bleed sometimes while you're elevating that up. Can I take the Gimmick now? And so this is kind of two-fold; some Gelfoam with epinephrine, not only for hemostasis, but then, you know, as I alluded to it being like a doorstop, as you push it into this groove, it allows you to have that tented open. We'll just gently kind of tuck that up. To keep that open. Okay. I'm going to go to a regular Rosen needle now, please. So for the superior elevation, I like to use the Rosen needle, kind of two-fold reason here, is you've got this nice curve, but also with the sharp point, and so you can use the back edge of it to gently push the tympanomeatal flap but if you come across any bands or adhesions like we're seeing here, you can kind of gently come through and take those down with the sharper edge of it. We're starting to see the stretching of the chorda tympani nerve right there, coming out of the bone. There's our malleus right there. We're starting to see the incudostapedial joint, coming into view there, our round window down here. I'm going to get a little bit more of this superior elevation here. Can I see the round knife, please? Let me just get a little bit more of this… Superior elevation. Okay. I'll take that Rosen needle again. Thank you. This is going to allow us to separate some of these adhesions here. That we have to the chorda tympani nerve and allow us to elevate our tympanomeatal flap without stretching that more than it should be. Let's see here, chorda's not through that . All right - Paulo, can I see a… So she's got a little adhesion even just right there. Let me see the Bellucci scissors. So I don't want to stretch this too much, and it's kind of getting to the point where it's clearly too thick to give on its own. And so… Let me see the 3 suction, please. Thank you. Thank you, Stephanie. Can I see the sickle knife now, please? Dr. Hoffer, you see she's got some scar bands there, just from the incus to the malleus. Yeah, I saw that. And even around this, where the stapes is. It's actually pretty significant scar tissue. Yeah. Nice. I think once we get this… Doctor, another advantage to an endoscopic technique, though, is you're able to get a close-up look at this. Oh, exactly. Position of all that. All right. Now, may I see the Rosen needle now? So what we're going to do is palpate our ossicular chain, and then I'll be switch - Rosen needle - and then I'm going to switch to the 30 degree here in just a second to get us a different look around. All right. So while we have this here, we're going to palpate our IS joint. And you can see that when we gently push on that, the joint is compressing, but the stapes itself is not moving. And the other thing that we'll do at this moment is to palpate the undersurface of the malleus, which again, results in pulling and stretching of that, as well as the incus and the IS joint, but the stapes itself remains fixed. I'm going to take a little bit of the scutum down here just to... Yeah. Just, I think, to be able to push the chorda posteriorly, I think that'll confer a bit of an advantage there.
Can I see the curette, please? But the scutum takedown will have to be a little bit less than it would be with a microscope. Oh, absolutely. And even sometimes, you don't need to take it down for viewing it, but you just need to take it down so that your instrument can work around it. Right? Because once we switch to angled instruments, sometimes you can see an area more than what you can reach with your instruments. So again, I'm not going to start my curetting right on top of the chorda. I'm going to come out and get this bone that's lateral here. And that's going to allow us to kind of gently thin that down. So note, Dom, that with the endoscope, he's able to see what he's curetting, whereas with the microscope, you just see the back of the curette. That's a great point, Dr. Hoffer. It allows me a little bit more safety, or at least a little bit more assurance in these moves. And again, this is the point as to why you want to make sure, you know, you don't need these really long tympanomeatal flaps in these cases, but you also can't sell yourself short because if you… If you do that and you end up taking down a lot of scutum then your flap can be short and won't reach, which is the last thing you want in a case like that. So again, we're taking this bone. This is okay for now. I'm not going to do too much more. I think this is the last little bit I'm going to try. And you have to be very careful when you get back to the insertion point of the chorda there. And we'll see whether or not we need to take any more. So let's see what we're dealing with here now. Yeah, what that's now allowed us to do is free up the chorda a little bit more. And see it going - coursing here? Again, this is a good relationship to note. Notice that it's going medial to the malleus but lateral to the incus, guys. All right? And without trying to stretch it too, too much here, I'm going to take down some of those adhesive bands.
You can see now, we have - there's our facial nerve right there. Let me point it out. Do you have a Rosen? So our facial nerve is right here. This is our pyramidal process from which the stapedial tendon emerges, going towards our stapes and IS joint. So like we said before, we've tested our ossicular chain. We can see that hypermobility of the incudostapedial joint, which is often indicative of otosclerosis in the case of a fixed stapes. We can see our footplate there in the distance, which does appear blue, so hopefully we don't have much work to do on the footplate there when the time comes.
So the next thing that we're going to do now is to separate the incudostapedial joint while we still have the stapedial tendon present in order to provide us with some countertraction. I'm going to take our incudostapedial joint knife. Basically, it looks like a very, very small round knife. So Dom, that's an important point. We're doing this with the… we want to use good countertraction so we don't… (indistinct). Let's see here. And I just kind of gently wiggle through that, Dom, because again, I should be allowing the sharp aspect of it to do that. An important thing is that after you do that, you're going to pull your instrument out. Don't pull it out while the cup of it is still under the medial portion of the lenticular process on the incus because you can avulse it. Okay? Let me see a laser. Can we go back down to 500, please? I'm just going to treat the joint so I can get the knife actually in a plane. Let’s go back to the knife now. Standby. I'm not liking my focus here. Got a lot of adhesions there. See that between the IS joint and the promontory? As I stretched that, You can see that actually stretching a little bit. So I think we're going to need to treat that as well. There we go, that's the joint separated now. Can I see the suction please?
Man, those curved suctions really would come in handy. The curved sections? I'm going to elevate that up to get myself some more light. All right, let's get the laser set back to 1 W, please. And I'll take the laser as well. So now our next step is going to be to separate the stapedial tendon. Suction. And the nice thing about the laser too, Dr. Hoffer brings up a great point that - yeah, the stapedial tendon can absolutely be excised sharply, but if we're using the laser for the duration of this case, then what's nice about this, is that we can go straight from… Yeah, a lot of adhesions around the stapes here. Is we can go straight from treating the stapedial tendon into - laser - into treating the posterior crus. Laser on. It says no probe. Or does it? It's not… There you go. Yeah. Suction. Paulo, I think this might be plugged. Hold on before I resolve you to that. Very tough angle. All right, I'm going to finish this part right here, and then we'll downfracture. Again, we're away from the - the nerve is very close there. Yeah.
Not prolapsed, not dehiscent. Laser. Laser beam. There we go. I feel good about getting this one. Laser on treat, please. There we go. Including that posterior crus. I'm going to get some of these little scar bands while I'm here. Okay, suction and then Rosen needle. So that's why, you know, the laser can be good for that over a sharp, just again, so you can kind of transition straight into taking the posterior crus with it. Hers was very weak. If some of these are like really dense, and you have to laser, and then kind of take a straight pick, and, you know, make sure that you've gotten all the ash kind of off of it, and then - the char off of it, rather. This is plugged. Can I see a Rosen needle now? What just came out? Thought I saw - sorry, I thought I saw something. That's the Rosen, right? Yep. So I've downfractured the stapes. It's just stuck, I think, to some of these bands. And so you can see, this is where I came through the posterior crus with the laser. That's where we had started our original IS joint. And then that's the anterior crura, which has been fractured off of the footplate. So the footplate, we know, is still in situ. Let me see an Alligator now, please. Now Dom, we have a measurement from the other side, which is the second side, but we're going to remeasure just to make sure. Correct, yeah. So this patient had her right side done about 5 months ago. And we used a - yeah, a complete closure - we used a 4.25x0.6. Where did that go? There it is. There you go. Really nice look at the anatomy. The facial nerve there, the chorda course, the incus, and that's at the footplate, and that scar tissue and debris is from the footplate. She's got a fair bit of it. Look at that. Very interesting. That's a remnant of the tendon there. The other advantage of the endoscope, Dom, is you can work underwater. That is very true. There we go, now we can see our footplate right there. Oh, I wonder if the footplate did come out. I'm wondering. Yeah, that's the posterior crus there. All right, so, I think we maybe need to get some fascia then, if the whole footplate's coming out. Yeah. See, that's actually the posterior aspect of it, not a hole or an opening. It must have avulsed anteriorly. Yeah, so we're going to need a little bit of perichondrium, right? To cover that. Yeah. Okay.
Let me give you this. 15 blade. Well it was all the scar tissue. Yeah, I mean I think that was part of it, certainly. So now, the question is what prosthesis do you want to put in? I guess we could do a bucket handle now and just do a 4x.0.4. Yeah, I mean… I will defer to Dr. Hoffer. Can I have a dry Raytec? So typically, when I do this, I do a bucket handle. Hey Dom? Yes. Can you kind of just hold this over where I'm going to work? When you have fascia, right? And you put in an anchor, and then you crimp, it can pull the fascia. Remember, Scott, when we were crimping last week, how it was changing the depth of the prosthesis? Yes. That's why I use a bucket handle. Yeah, I agree. I like that. Yeah, so we need a 4… 4x0.4, right? I'm not sure if we can get it brighter, it's not looking great. Let's get the light back on there. Okay, so, because of the conversion to a stapedectomy here, what we've done now is we've gone and we've obtained a small piece of perichondrium from the tragus. You know, we were just discussing that needing to convert and to do that isn't a huge deal, but it's a good thing to know how to be able to do. It only adds about a minute and a half onto what we needed to do.
And so now we're going to finish taking out the remainder of that footplate, gently here. Can I see the Hough Hoe now? So, now this is important, Dom, if you don't want that footplat to fall in. Right. It's a fractured footplate so we have to take it out. And I guess technically, we might be able to like, pushed it back in, but… I don't want to burn my chorda with the lamp. You know, it might be. Oh, so that's what you don't want. Shit. Okay. Suction please. What's that instrument? I'm sorry, this is a Hough Hoe. I'm sorry? Hough Hoe. Hough hoe. H-O-U-G-H. So now the posterior crus remnant is off of it. Okay, so let us take a Rosen needle now. I'm going to get a Rosen underneath that and bring it out. And it may actually, we may end up just with like a partial platinectomy there, with the posterior part of it. Yeah, which is fine. Very nice, my friend. Thank you. Not out of the woods quite yet. Okay, fascia, please. That's the vestibule. I'll get it. I'll get it in a minute. I want to get the vestibule covered first. Actually no, no - you're right. Let me see the right angle. Sorry. No, no, no, I agree. I agree. I mean even this still has some adhesions to it. Okay. Alligator. Yeah. All of that. A little caught on the bone there.
So Dom, we did not evulse the entire footplate with the downfracture, we just kind of take a big piece of it. Okay. This side facing up is the cartilage side? I think it's the flat part there. Sorry, there's a little piece of it... Okay. Sort of right there. I think it's just tubes. Golly day. All right, just give me a Rosen needle, please. Rosen needle. Yeah, exactly. It's bloodier on this side, yeah? Yep, sure is. He does this every time. I know, right? I mean, if you've got a way, you've got a way, right? All right, suction, please. What's that? What? What's that? Yeah, exactly. One or two. I think that's got good coverage of the vestibule there. That's great. Okay, now for the - I don't think I've put a Robinson in endoscopically before, so that'll be interesting.
I have an idea. Ohh. Okay. Can I see the Rosen? And then have the Hough Hoe ready. Hough Hoe? Yeah… Not out of the woods yet, let's see, let's finish it off. Suction. Okay, let me see a Gimmick. I don't think I'm - there's too much scar tissue there, I just want to make sure it… Yeah, it doesn't… Okay. Suction, please. Endoscopic stapedectomy, actually that's… That's an interesting one. That's one for the books. Endoscopic stapedotomy, conversion stapedectomy. On purpose. Yes. Well because of the scar tissue. Well, because I avulsed it. The avulsion, Scott, was because of the scar tissue. I agree. You can't - you can only… Hey, stay with me. You would have had to literally have lasered every piece of star tissue… Yeah, I know.
So we don't usually suction on the flap, but this is a nice way to kind of get it to roll back. The way that we want to. Can I see an Alligator? I was like so excited - the injection was good, and I was like oh money, this is going to be super quick. Well we've done some of these in like 45 minutes, just endoscopically, which isn't bad. Suction again. So just very important to make sure that all of your edges have been unrolled. You don't want to get skin rolled under itself, which can create, you know, canal cholesteatomas and the like. So we get that to roll out nicely. And then I'll take a Gimmick, please. And if you've used Gelfoam to kind of keep the edges of the annulus up on each end, just make sure that you've taken those out or else things will not fold down nicely. Exactly. Yeah. Okay. Gelfoam. Yes, 100%. Okay. Because of the vestibule, and also a lot of scar tissue. She probably - it depends on how many Gelfoams you put down. You may not... (indistinct). The endoscopic flaps, because of the fact that they're done a little more gently, sometimes…