The Laryngoscope

© 2018 The American Laryngological,

Rhinological and Otological Society, Inc.

Comparison of Endoscopic and Microscopic Ear Surgery in Pediatric

Patients: A Meta-analysis

Sang-Yoon Han, MD; Doh Young Lee, MD, PhD; Juyong Chung, MD and Young Ho Kim, MD, PhD

Objectives: Recently, the endoscope has been increasingly introduced for middle-ear surgery. To evaluate the postopera-
tive outcomes of endoscopic ear surgery (EES) in pediatric patients, we did a qualitative analysis with a systematic review and
quantitative analysis with meta-analysis of available literature.
Methods: Studies reporting the comparative surgical outcomes of EES in pediatric patients were systematically reviewed
by searching the MEDLINE, PubMed, and Embase databases from database inception through 2017. The selected articles
included clinical studies conducted with at least 30 subjects and at least one postoperative parameter, including residual or
recurrent cholesteatoma and graft success in tympanoplasty. Two investigators independently reviewed all studies and
extracted the data using a standardized form. A meta-analysis was performed using a random-effects model and qualitative
review was performed on the smaller studies.
Results: Ten studies were identified as appropriate for quantitative meta-analysis and 19 studies for qualitative analysis.
In the meta-analysis, residual or recurrence rate of cholesteatoma was significantly lower in the EES group than in the micro-
scopic ear surgery (MES) group (odds ratio [OR]: 0.56, 95% confidence interval [CI]: 0.38-0.84, P = .005). The graft success
rate of tympanoplasty was not statistically different between EES and MES groups (OR: 0.72, 95% CI: 0.41-1.26, P = .249). In
the qualitative analysis, most of the studies reported similar audiological outcomes after tympanoplasty and success rate of
cholesteatoma removal between the two groups.
Conclusions: It appears that EES reduces the risk of residual cholesteatoma in children and that the success of perfora-
tion closure is equivalent to MES.
Laryngoscope, 00:1–9, 2018

INTRODUCTION Despite the advantages of endoscopic surgery in

Endoscopic ear surgery (EES) is a recently intro-
duced technique to evaluate the degree of disease and
eradicate residual disease via endoscopy or as a combined
tool in microscopic ear surgery (MES).1,2 This technique
has several advantages over conventional MES: 1) effec-
tive access to the middle ear with a smaller incision,3,4
and 2) a wider operative view with an increased angle of
vision.5,6 With the increased application of EES to
middle-ear diseases, EES is emerging as an option in
tympanoplasty or myringoplasty. Moreover, the indica-
tions with this technique have widened to pediatric
middle-ear disease.7
From the Department of Otorhinolaryngology–Head and Neck
Surgery(S.-Y.H., D.Y.L., Y.H.K.), Seoul National University Boramae Medical
Center, Seoul National University College of Medicine, Seoul, South
Korea; the Department of Otolaryngology–Head and Neck Surgery(J.C.),
Wonkwang University School of Medicine, Iksan, Korea
Additional Supporting Information may be found in the online ver-
sion of this article.
Editor’s Note: This Manuscript was accepted for publication August
13, 2018.
S.-Y.H. and D.Y.L. contributed equally to this work.
This study was supported by a clinical research grant provided from
Seoul National University Boramae Medical Center.
The authors have no other funding, financial relationships, or con-
flicts of interest to disclose.
Send correspondence to Young Ho Kim, MD, PhD, Department of
Otolaryngology–Head and Neck Surgery, Seoul National University Bora-
mae Medical Center, Seoul National University College of Medicine, 5 Gil
20, Boramae-Road, Dongjak-Gu, Seoul 156-707, Korea. E-
mail: yhkiment@gmail.com
DOI: 10.1002/lary.27556
middle-ear diseases, EES has several limitations, espe-
cially in pediatric application, because the external audi-
tory canal is small. The main limitation is having to
perform a single-handed technique, with the other hand
holding the endoscope, which is disadvantageous during
fine dissection. Second, EES is not an appropriate
approach in middle-ear diseases extending to the mastoid
or further. Therefore, EES may be used in diseases lim-
ited to middle ears, such as early-stage pediatric choles-
teatoma, simple tympanoplasty, or conductive hearing
loss.8 Last, EES has its own learning curve, and the oper-
ation time is known to be longer than that of conventional
MES.9 The appropriate application of EES in pediatric
patients with middle-ear diseases is important, although
there is no quantitative analysis of surgical outcomes of
EES compared with those of MES, to the best of our
knowledge.
The aim of this study was to evaluate the postopera-
tive outcomes of EES in pediatric patients with chronic
middle-ear diseases by means of a systematic review and
a meta-analysis of the available literature. These will
reveal advantages and limitations of EES in comparison
with classical MES in children.
MATERIALS AND METHODS
This systematic review and meta-analysis was developed
and performed according to the recommendations of the Pre-
ferred Reporting Items for Systematic Reviews and Meta-

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1
Analyses (PRISMA). The PRISMA Flow Diagram was used to
outline the various phases of the systematic review.10 This study
used quantitative methods to examine reasons for differences in
postoperative outcomes.
Selection Criteria
On January 1, 2018, two of the authors (J.C. and Y.H.K.)
independently searched the MEDLINE, PubMed, and
EMBASE databases for articles published between database
inception and 2017 for all available studies reporting postoper-
ative outcomes of pediatric EES. We independently screened
the titles and abstracts of all nonduplicated articles and
excluded irrelevant titles and abstracts. A final list was agreed
upon, with discrepancies on the eligibility of studies resolved
by consensus. The following terms were used for the literature
search: (“ear” OR “otitis” OR “cholesteatoma” OR “stapes” OR
“stapedial” OR “mastoid” OR “tympan*” OR “otosclerosis” OR
“ossic*”) AND (“endoscope” OR “endoscopic”). We identified
additional relevant manuscripts from the references of
included studies.
Inclusion and Exclusion Criteria
The inclusion criteria for our meta-analysis of pediatric
EES studies were as follows: 1) report of at least one postopera-
tive outcome (residual disease or recurrence in pediatric choles-
teatoma and graft success in tympanoplasty), 2) original articles
from peer-reviewed scientific journals published in English, and
3) studies with children and youth aged 18 years or younger. The
following types of publications were excluded: 1) animal studies,
in vitro studies, review articles, case reports, and abstracts; 2)
studies without access to original articles (e.g., only abstracts)
and/or with incomplete data; and 3) duplicate publications.
We did not contact study authors to identify additional
information and further studies. In addition, we assessed the
risk of bias of the studies included in the qualitative review
based on Newcastle-Ottawa Scale criteria, and all of the studies
showed good or fair quality (see Supporting Information, Table I,
in the online version of this article). The EES group included
both totally endoscopic ear surgery and endoscope-assisted
microscope-guided surgery.
Data Extraction
We reviewed all studies and independently performed
data extraction; any discrepancies were resolved by consensus.
For each article that reported postoperative outcomes of pediat-
ric EES, the following information was noted: author, year of
publication, number of patients, and postoperative outcomes.
The analysis of pooled proportions was performed, and cases
with missing or incomplete information were excluded.
Weighted proportions and their 95% confidence intervals (CIs)
for the percentage of residual/recurrence disease of cholestea-
toma and graft success were calculated. Studies without any
comparison (e.g., case series) were subjected to qualitative
analysis.
Statistical Analysis
Both a fixed-effect model and a random-effects model
were used. A random-effects model was adopted when the het-
erogeneity study revealed that the involved studies had incon-
sistent Cochran Q test results and I2 statistics (for the
percentage of overall variation). A P value < .01 for the
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Cochran Q test indicated significant heterogeneity between
studies. The I2 statistic describes the percentage of total varia-
tion across studies due to heterogeneity rather than chance;
thus, I2 < 25%, I2 = 25% to 50%, and I2 > 50% represented low,
moderate, and high degrees of inconsistency, respectively.11
All the statistical analyses in this meta-analysis were per-
formed using the software package R for Windows, version
3.3.2 (R Foundation for Statistical Computing, Vienna,
Austria).
RESULTS
Characteristics of the Studies
A flow diagram of the initial identification, reasons
for exclusion, and final selection of studies is shown in
Figure 1. The search strategy identified 4,288 unique
abstracts, including 211 that met the initial screening
criteria. After reviewing the full-length articles,
182 studies were excluded because they contained a mix-
ture of different patient populations (e.g., mixture of
adult and pediatric patients) in the total cohort
(n = 163), lacked postoperative outcomes (n = 14), or
were review articles (n = 5). Ten studies met all the
inclusion criteria for the meta-analysis; two were pro-
spective and eight were retrospective cohort studies
(Table I).4,12–20 The number of subjects collected for
meta-analysis was 1004, including 513 patients belong-
ing to EES and 491 patients under MES, and the
included studies were published between 2015 and 2017.
Nineteen studies were analyzed qualitatively, which
were all case series studies, except for one retrospective
cohort study (Table II).8,21–38 The included studies were
published between 1995 and 2017, and a total of
406 patients were evaluated.
Residual Cholesteatoma or Its Recurrence After
EES in Pediatric Cholesteatoma
Among the 10 studies enrolled in the quantitative
meta-analysis, postoperative residual cholesteatoma or
its recurrence was investigated in six studies. Residual
cholesteatoma or its recurrence rate was significantly
lower in EES than in MES (odds ratio: 0.56, 95% CI:
0.38-0.84, P = .005; Fig. 2A). Among the 19 studies
enrolled in qualitative analysis, 10 investigated the recur-
rence rate of cholesteatoma after surgery (Table II). The
recurrence rate of cholesteatoma after EES ranged from
zero to 50%.
In these qualitative studies, the stage of cholestea-
toma was a factor for successful postoperative outcomes.
Congenital cholesteatoma (CC) in the Potsic stage39 I, II,
III, and selective IV was considered as an appropriate
indication for EES (Table III). A rate of residual lesion or
recurrence of stage I CC was equivalent to that of stage
II CC. However, residual lesions in stage III CC were
higher than in stage I or stage II CC.24,31,33,37 The most
frequent sites of residual or recurrence cholesteatoma
and intraoperative detection of cholesteatoma were epi-
tympanum, around stapes, and around the facial nerve
(including sinus tympani) (Table III).
Han et al.: Pediatric Endoscopic Ear Surgery
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TABLE I.
Summary of Clinical Characteristics of 10 EES Studies Enrolled in Quantitative Meta-analysis4,12–20
No. of Subjects Age, yr Treatment in Control F/U Period, mo Postoperative Outcomes, %
Study Study Design Diagnosis (EES/MES) (Range) Group (Range) Parameters (EES/MES)

Cohen et al. Retrospective Cholesteatoma 39/25 11.0 MES — Residual 23.1/24.0

(2017) 13 cohort (6.7–13) cholesteatoma
Ghadersohi et al. Retrospective Cholesteatoma 47/18 10.9 MES 31.2 (9–55.2) Residual 29.8/50.0
(2017) 15 cohort cholesteatoma
Hunter et al. (2016) Retrospective Cholesteatoma 29/47 10.9 (4–18) MES 18.8 (6.7–48.3) Residual 10.3/8.5
16
cohort cholesteatoma
James et al. (2016) Prospective Cholesteatoma 127/108 10.9 MES >38 Residual 15.0/24.1
18
cohort (1–17.9) cholesteatoma
Basonbul et al. Retrospective Cholesteatoma 56/33 — MES — Residual 32.1/48.5
(2016) 12 cohort cholesteatoma
Marchioni et al. Retrospective Cholesteatoma 31/28 8.7 MES 31.2 (9–55.2) Residual 32.3/53.6
(2015) 19 cohort (1.2–17.8) cholesteatoma,
hearing gain
James et al. (2017) Prospective COM 111/167 12.7 MES 12 Graft success 82.0/87.4
17
cohort
Dündar et al. (2014) 4 Retrospective COM 32/29 12.4 (7–16) MES 10 Graft success, 87.5/93.1
cohort hearing gain
Cohen et al. (2016) Retrospective COM 19/13 9.8 MES 6–12 Graft success, 79.0/84.6
14
cohort hearing gain
Nassif et al. (2015) 20 Retrospective COM 22/23 10.0 (5–16) MES >12 Graft success, 90.9/82.6
cohort hearing gain
Cholesteatoma (6 Cholesteatoma 329/259
studies)
COM (4 studies) COM 184/232
Total 513/491

COM = chronic otitis media; EES = endoscopic ear surgery; F/U = follow up; MES = microscopic ear surgery.

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Han et al.: Pediatric Endoscopic Ear Surgery
Fig. 1. PRISMA flow diagram outlining the study design. PRISMA = Preferred Reporting Items for Systematic Reviews and Meta-Analyses.
[Color figure can be viewed in the online issue, which is available at www.laryngoscope.com.]
Graft Success in Tympanoplasty
Four studies enrolled in the quantitative meta-
analysis investigated postoperative graft success rate. In
tympanoplasty, the graft success rate showed no signifi-
cant difference between the EES and MES groups (odds
ratio: 0.72, 95% CI: 0.41-1.26, P = .249; Fig. 2B). Among
the 19 studies enrolled in the qualitative analysis, seven
studies investigated graft-failure rate after tympano-
plasty, which ranged from zero to 13.6% (Table II). In
these studies, the size and location of tympanic mem-
brane perforation affected the graft-failure rate. One
study considered perforation diameter >3 mm as a cutoff
point for tympanic membrane perforation.21 Another
study considered a perforation >50% of tympanic mem-
brane as the cutoff.22 Other studies investigated the rele-
vance of perforation size and re-perforation. Larger
perforation was related to higher graft-failure rate in
these studies. Furthermore, the location of tympanic
membrane perforation affected graft-failure rate
(Table IV). When dividing the location of tympanic mem-
brane perforation into anterior and posterior, one study
reported no difference between the two perforation loca-
tions.35 On the other hand, another study showed that
the marginal and posterior tympanic membrane perfora-
tion was a risk factor for graft failure.22 Furthermore,
there was no obvious relevance between age, canal diame-
ter, and recurrence rate in these studies. In general,
younger patients’ canal diameter was shorter than that of
older ones; that is, the EES technique could be very com-
plicated in younger patients with narrower canal diame-
ter, compared with adult patients. However, in these
studies, age and canal diameter in patients with normal
external auditory canal did not have a critical effect on
EES results.22,29,31
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DISCUSSION
Endoscopy in the otologic field was first introduced
in the 1960s; however, it was not applied widely because
of poor resolution and imaging quality. With the inven-
tion of high-resolution endoscopes and charge-coupled
device cameras, endoscopes were actively introduced for
sinus surgery in the 1990s. Subsequently, the perfor-
mance of endoscopes improved significantly, and wide-
angled surgical view was secured by using angled endo-
scopes. In the otologic field, operators obtained benefits
similar to MES by using endoscopes, and the application
of EES increased gradually.40
The indications for EES have extended. The early
period of EES involved myringoplasty or simple tym-
panoplasty. Early-stage cholesteatoma was removed
successfully. Kojima et al. and Hunter et al. have
reported the application of endoscopes in stapes sur-
gery40,41 and found that ear endoscopes could be used
for stapes surgery by experienced surgeons. Dia
et al. and Marchioni et al. suggested the utility of
endoscopes in cochlear implantations. 42,43 Further-
more, endoscopes were used in the management of
middle-ear benign tumors, such as paraganglioma, car-
cinoid tumors, and osteoma.44,45
EES has various advantages and disadvantages.
Transcanal EES was associated with minimal surgical
scar. However, the cosmetic advantage of EES was not
emphasized in all otologic ear diseases, especially in pedi-
atric cholesteatoma cases, because EES was performed to
remove pathological lesions as completely as possible.
EES facilitates the identification and removal of choles-
teatoma or inflammatory tissue in the blind spot beyond
the reach of MES. In addition, surgical time is reduced
with EES.
Han et al.: Pediatric Endoscopic Ear Surgery
 TABLE II.
Summary of Clinical Characteristics of 19 EES Studies Enrolled in Qualitative Analysis.8,21–38
No. of Age, yr F/U Postoperative
Study Study Design Diagnosis Subjects (Range) Period, mo Parameters Outcomes, %

Marchioni et al. (2017) Retrospective Cholesteatoma 12 (6/6) 4 (2–7) 54.5 RCR 0.0
33
cohort
D’Eredita et al. (2017) 24 Case series Cholesteatoma 12 3.5 (1.5–6) 7 RCR/hearing gain 0.0/equivocal
Sarcu et al. (2016) 37 Case series Cholesteatoma 42 1–16 >15 RCR 16.7
Landegger et al. (2016) Case series Cholesteatoma/ 5 5 (6–12) 6 RCR 0.0
32
CHL
Huang and Sun (2016) Case series Cholesteatoma 2 — 6 RCR 0.0
34

Huang and Sun (2016) Case series Cholesteatoma 13 6.9 ± 4.3 6–24 RCR/graft failure 0.0/0.0
26
/COM
Ito et al. (2015) 29 Case series Cholesteatoma/ 31 7.6 (2–13) — RCR/graft failure/ 6.3/0.0/10.4 dB
COM/CHL hearing gain
Kobayashi et al. (2015) Case series Cholesteatoma 12 3 (1–16) 48 RCR 8.3
31

Kanotra and James Case series Cholesteatoma 27 6.9 (3–15) 0 IDRC 18.5
(2012) 30
Good and Isaacson Case series Cholesteatoma 29 — — IDRC 24.0
(1999) 25
Rosenberg et al. (1995) Case series Cholesteatoma 10 11.1 25.4 RCR 50.0
36

De Zinis et al. (2017) 8 Case series COM 10 10 (6–14) — Graft failure/hearing 0.0/6 dB
gain
Akyigit et al. (2017) 21 Case series COM 32 13.9 (8–17) 23.3 Graft failure/hearing 6.3/10.5 dB
gain
Isaacson and Harounian Case series COM 31 6 (3.5–17) — Graft failure 12.9
(2017) 28
Awad et al. (2015) 22 Case series COM 80 11 (5–17) 6 Graft failure/hearing 13.0/23.7 dB
gain
Migirov and Wolf (2015) Case series COM 22 10.7 (5–16) 12 Graft failure/hearing 13.6/14.6 dB
35
gain
Carter et al. (2017) 23 Case series CHL 21 8.0 25.2 Graft failure/hearing 0.0/12.4 dB
(4–15.8) gain
Zhu et al. (2016) 38 Case series CHL 8 10.1 (6–12) 6 Hearing gain 18.9 dB
Isaacson et al. (2015) 27 Case series CHL 8 6–18 Hearing gain Improved
Cholesteatoma Cholesteatoma 194
COM COM 219
CHL CHL 72
Total 406

CHL = conductive hearing loss; COM = chronic otitis media; EES = endoscopic ear surgery; F/U = follow up; IDRC = intraoperative detection of residual
cholesteatoma; RCR = residual cholesteatoma or recurrence.

However, we cannot overlook the following limita-
tions. First, it is basically a one-handed technique,
because the other hand is used to grip the endoscope.
Therefore, it may be very difficult in special conditions,
such as massive bleeding. Preyer suggested that EES
cannot fully substitute for the use of a microscope because
of the limitation associated with the single-hand tech-
nique.46 Second, EES is associated with a potential risk
of damage to the surrounding structures not included in
the visual field, such as ossicles, nerves (including facial
nerves and the chorda tympani nerve), and other sur-
rounding tissues.9 EES in pediatric patients with a nar-
row ear canal requires great care. Third, the heat of the
endoscope light may induce thermal damage to inner-ear
structures. Therefore, the brightness of the light source
should be adjusted during the surgical preparation.40,47
A few techniques to overcome the limitations of EES
were developed. The double-handed technique supported
by the endoscope-holding system was introduced in pre-
liminary studies.8,48–50 This technique increased the
effectiveness of the surgery over that of the one-handed
EES if the stability of the holding system was guaran-
teed. Furthermore, ear endoscopy may be used for total
EES or observation of the middle ear before and after
MES. Observational practices of ear endoscopy in the con-
ventional MES before the start of full-scale total EES will
assist beginners in learning the surgical skills of EES.
This study demonstrated that the control rate of
residual cholesteatoma after EES was higher than that of
MES and the graft success rate after EES was similar to
that of MES in qualitative studies. The graft-failure rate
ranged from zero to 13.6%, which was similar to that of

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Fig. 2. Forest plot. Comparative analysis of residual cholesteatoma or its recurrence (A) and graft success of tympanic membrane (B) of endo-
scopic and microscopic ear surgery. CI = confidence interval; EES = endoscopic ear surgery; MES = microscopic ear surgery; OR = odds
ratio.
MES.51,52 The recurrence rate of cholesteatoma after EES
in this study was similar to that of MES (4%–15%).53 A
few studies evaluated the efficacy of EES for intraopera-
tive detection of residual cholesteatoma.25,30 In these
studies, 18.5% to 24.0% of residual cholesteatoma cases
were detected with endoscopes during MES. Although
EES showed results similar to or better than those of
MES in a few situations, no large cohort studies were
available to date. Therefore, a significant publication bias
may be present, suggesting that the worst outcomes of
EES were not reported. Interestingly, there was no report
of significant complications after EES in this review. Fur-
ther studies are needed to investigate the surgical prob-
lems or complications in patients who underwent EES,
especially in pediatric EES cases. Additional studies with
larger cohorts are needed for clarification.
Compared with previously published systemic
reviews of EES, this study was designed for only pediatric
patients. Presutti et al. and Kozin et al. performed sys-
tematic reviews targeting all ages for EES.54,55 Therefore,
their results may have heterogeneity for age in EES. In
the present study, we selected only pediatric patients to
investigate the efficacy of EES in children with a narrow
surgical field.
This study has a few limitations. First, only a few
published articles reported the quantitative analysis of
EES compared with other techniques; this precluded
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sensitivity or subgroup analysis in the present study.
Although residual and recurrent cholesteatoma should
be analyzed separately, having so few studies made it
difficult to perform subgroup analysis. Moreover,
because of the lack of information about follow-up
periods and timing of recurrences, a survival analysis
using a time variable was not possible. Second, the stage
of cholesteatoma or size of the perforated tympanic
membrane was not reported in most studies, complicat-
ing the analysis of factors affecting the extent of dis-
eases. The residual or recurrence rate according to the
stage of cholesteatoma and graft-success rate based on
the size of the perforated tympanic membrane need to
be further investigated. Third, a publication bias was
observed in most of the risk-factor analyses. Among the
studies included in this meta-analysis, an epidemiologic
analysis may compromise the consistency of the included
articles and results. Fourth, studies in languages other
than English were excluded; they might have reported
different results. Last, demographic factors such as age
were not adjusted, although age may contribute to the
success of EES. Despite limitation of possible heteroge-
neity and bias in this study, its results may facilitate
decision-making and outcome prediction for EES. Fur-
ther clinical and basic studies are needed to elucidate
the factors related to successful treatment outcomes of
EES in pediatric patients.
Han et al.: Pediatric Endoscopic Ear Surgery
 Laryngoscope
TABLE III.
Summary of Studies of Cholesteatoma EES That Had Data on Primary Site, Residual or Recurrence Site, Stage, and Type
Potsic Stage (Surgery Type/Case/Recurrence Case)
Type of
Study Cholesteatoma I II III IV Site of Cholesteatoma RCR Site IDRC Site

Marchioni et al. Congenital (all) TEES/3/0 TEES/1/0 TEES with CWU with — — —
(2017) ossiculoplasty/5/0, EES/2/0
EES with CWU/2/0
D’Eredita et al. — –/7/– –/4/– –/1/– — — — —
(2017)
Landegger et al. Congenital (1), acquired Oval window (1)
(2016) (2)
Sarcu et al. (2016) Congenital (7), acquired — — — — — Oval window Oval window (3),
(35) (2), pyramidal eminence
stapes (1) (2),
sinus tympani (2)
Ito et al. (2015) Congenital (13), acquired — — — — — —
(3)
Kobayashi et al. Congenital TEES TEES TEES T3/1/1 — ASQ (7), PSQ+PIQ (2), Horizontal —
(2015) closed (7), TI/7ear/0 TI/4/0 ASQ+AIQ (1), ASQ+PSQ (1), portion
congenital open ASQ–difficult to endoscopic of FN and
(5), open type surgery facial recess
recur (1)
Kanotra (2012) — –/39.2%/– –/35.7%/– –/25.0%/– — — — Sinus tympani (4),
anterior
epitympanum (1)
Rosenberg et al. — — — — — — Stapes crura, —
(1995) epitympanum

AIQ = anterior inferior quadrant; ASQ = anterior superior quadrant; CWU = canal wall up mastoidectomy; EES, endoscopic ear surgery; FN = facial nerve; IDRC = intraoperative detection of residual choles-
teatoma; N = number; PIQ = posterior inferior quadrant; PSQ = posterior superior quadrant; RCR = residual cholesteatoma or recurrence; TEES = transcanal endoscopic ear surgery.

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Han et al.: Pediatric Endoscopic Ear Surgery
 TABLE IV.
Summary of Studies of EES for Chronic Otitis Media That Had Data on Perforation Site, Size, Recurrence Site, and Audiometric Results
Study Perforation Site/N/SR, % Perforation Size/N/SR, % TM Graft Audiometry Results

Awad et al. Central/30/90, anterior/20/95, >50%/25/92, ≤ 50%/55/85 Tragal cartilage 1–10 years old ABG: pre, 30.5
(2015) inferior/16/88, posterior/9/78, dB/post, 8.0 dB; 11–17 years old
marginal/5/60 ABG: pre, 35.5 dB/post, 10.5 dB
Akyigit et al. Anterior/9/28.1, posterior/6/18.8, both ≥3 mm/12/100, Cartilage Pre ABG: 18.5 ± 6.29; post ABG:
(2017) (ant-post)/17/53.1 3–6 mm/20/93.7 7.96 ± 3.32; 0–10 dB ABG: pre 4
(12.5%), post 25 (78.1%); 11–20 dB
ABG: pre 16 (50%), post 7 (21.9%);
21–30 dB ABG: pre 12 (37.5%)
Carter et al. Pre PTA: 43.82 dB (range, 17.5–63.75);
(2017) post PTA: 31.38 dB (range,
15–66.25); AC gain: 11.65 dB
(range, –10 to 36.25); ABG gain:
10.19 dB (range, –11.25 to 28.75)
Ito et al. Large/5/100, Hearing level was 28.2  14.1 dB;
(2015) moderate/4/100, ABG was 8.6  8.3
adhesive/2/100
Migirov et Anterior/14/100 (difficulty to approach Large/13/100, Chondro-perichondrial Pre AC: 32.8 dB (range, 10–51.3); post
al. (2015) due to overhanging, narrowness); medium/8/100, flap AC: 18.2 dB (range, 5–35)
central/2/100; posterior marginal/6/100 small/1/100

Some data are reported as ±SD.

ABG = air-bone gap; AC = air conduction; N = number; Post = postoperative; Pre = preoperative; PTA = pure tone audiometry; SD = standard deviation;
SR = success rate; TM = tympanic membrane.

CONCLUSION
EES appears to outscore or be comparable with con-
ventional MES in patient outcome. In addition, the possi-
bility of residual cholesteatoma or its recurrence in
pediatric cholesteatoma was reduced by the removal of
cholesteatoma using EES. However, further evidence-
based studies about safety and postoperative outcomes of
EES in pediatric patients are needed.
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