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Endoscopic ear surgery in Canada: a cross-sectional study Yong, Michael; Mijovic, Tamara; Lea, Jane Jan 19, 2016

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ORIGINAL RESEARCH ARTICLE Open AccessEndoscopic ear surgery in Canada:a cross-sectional studyMichael Yong1, Tamara Mijovic2 and Jane Lea3*AbstractBackground: Endoscopic ear surgery is an emerging technique with recent literature highlighting advantages overthe traditional microscopic approach. This study aims to characterize the current status of endoscopic ear surgery inCanada and better understand the beliefs and concerns of the otolaryngology – head & neck surgery communityregarding this technique.Methods: A cross-sectional survey study of Canadian otolaryngologists was performed. Members of the CanadianSociety of Otolaryngology were contacted though an online survey carried out in 2015.Results: The majority of participants in this study (70 %) used an endoscope in their practice, with a large proportionutilizing the endoscope for cholesteatoma or tympanoplasty surgery. To date, 38 Canadian otolaryngologists (70 %of respondents) have used an endoscope for at least 1 surgical case, but only 6 (11 %) have performed more than 50endoscopic cases. Of the otolaryngologists who use endoscopes regularly, the majority still use the microscope as theirprimary instrument and use the endoscope only as an adjunct during surgery. However, the general attitude surroundingendoscopes is positive; 81 % believe that endoscopes have a role to play in the future of ear surgery and 53 % indicatedthey were likely to use endoscopes in their future practice. Participants who were earlier in their practice or whohad more exposure to endoscopic techniques in their career were more likely to have a positive stance towardsendoscopic ear surgery (p < 0.05, p < 0.01, respectively). The main concern regarding endoscopic ear surgery wasthe technical challenge of one-handed surgery, while the primary perceived advantage was the reduced rates ofresidual or recurrent disease.Conclusions: Endoscopic ear surgery is a new technique that is gaining momentum in Canada and there is enthusiasmfor its incorporation into future practice. Further investment in training courses and guidance for those looking to start oradvance the use of endoscopes in their practice will be vital in the years to come.Keywords: Endoscopic ear surgery, Middle ear surgery, Otology, Survey, CanadaBackgroundThe use of endoscopes in ear surgery began approximatelyforty years ago; however, it is only recently that enthusiasmfor this technique has grown. Acceptance of endoscopicear surgery techniques has likewise grown [1], albeit slowlyand with initial great resistance. Over the past decade, nu-merous studies have been published on the overall efficacyof endoscopic ear surgery as compared to the traditionalmicroscopic approach, thus promoting wider usage of theendoscope [2–6]. The endoscope has been supported as atool for improving the visual exposure of hidden structuresand deep recesses, obtaining a wider angle of view, andachieving a minimally-invasive operation with greaterhealthy tissue preservation [4–6]. The ability to view blindspots during surgeries for diseases such as cholesteatomahas also been shown to decrease residual disease and re-currence rates when compared to surgeries which used themicroscope alone [6, 7].While some authors are optimistic that endoscopeswill become increasingly utilized and important inotologic surgery due to the cumulative advances intechnique and quality of equipment [4–6], there are stillsome concerns over safety and efficiency that contributeto the reluctance of some ear surgeons to adopt usage of* Correspondence: jlea@providencehealth.bc.ca3University of British Columbia, Division of Otolaryngology – Head and NeckSurgery, ENT Clinic, 1081 Burrard Street, St. Paul’s Hospital, Vancouver, BC V6Z1Y6, CanadaFull list of author information is available at the end of the article© 2016 Yong et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Yong et al. Journal of Otolaryngology - Head and Neck Surgery  (2016) 45:4 DOI 10.1186/s40463-016-0117-7this technique. Careful control of hemorrhage, anti-fogging methods, reducing potential endoscope-associatedthermal injury, and compensation for the loss of depthperception are challenges that need addressing whenmaximizing the safety of the procedure [5, 8, 9]. Inaddition, the cost of endoscopic equipment and the needfor specialized training and experience is a hurdle that canfurther deter surgeons who already practice exclu-sively with the microscope from embracing this newtechnique [5, 8].At the present time, there are no studies that characterizethe usage patterns of endoscopes among those whoperform ear surgery in Canada. Given the improvements intechnology and changes made to the endoscopic techniqueover the past four decades, an assessment of the currentattitudes towards endoscopic ear surgery will provide somevaluable insight on the role this approach currently playsand may play in the future. The objective of this study wasto provide an analysis of the current usage of endoscopicear surgery techniques among Canadian otolaryngologists,as well as obtain a better understanding of the attitudesand learning experiences surrounding endoscopic earsurgery in Canada.MethodsFollowing approval by the UBC Behavioural ResearchEthics Board (ID H14-03499), members of the CanadianSociety of Otolaryngology were contacted by email andinvited to participate in an on-line survey. Subject invita-tion and recruitment were facilitated using the CanadianSociety of Otolaryngology’s e-mail listserv and took placeduring a 6-week period from March 2015 to April 2015.Consent was obtained from each study participant touse the anonymous study data collected for the purposesof publication.This cross-sectional study involved an online surveyquestionnaire administered through FluidSurveys (Ottawa,ON, Canada). It was composed of eleven main questions(Additional file 1) aimed at characterizing the subjects’surgical experience, use of endoscopes in ear surgery, andperceived advantages and concerns with endoscopic earsurgery techniques. This survey was not pre-validatedbecause no similar characterizations of endoscope usagehave been previously conducted.Statistical analysisDescriptive statistics were used to characterize thecurrent use of endoscopes and identify the concerns andattitudes held by otolaryngologists regarding the use ofendoscopes in ear surgery.Study participants were divided into categories basedon the number of years in practice and the number ofendoscopic ear cases performed. These two categoricalsub-groups were then used as factors against which theresponses to various continuous and categorical variablesurvey questions were analyzed. In particular, three mainquestions regarding the likelihood to use endoscopes inthe future, overall learning experience with endoscopes,and belief in a role for endoscopes in ear surgery in thefuture were chosen for statistical analysis. Furthermore,three additional questions regarding concerns, advan-tages, and ease of use were analyzed for descriptivepurposes.Odds ratio calculations comparing various pre-determined sub-groups were conducted for three keyquestions which were felt to best represent the overallattitude towards using endoscopes in ear surgery(Questions 7, 10, and 11). In addition, cross-tabulations(Pearson’s chi-square test and Fishers exact test forsmall sample sizes) were conducted for the categoricaldata in Questions 7 and 10 and one-way ANOVAanalysis was conducted for the continuous variable datain Question 11. Rigorous statistical analysis excludeddata from resident physicians due to lack of adequatesample size. These data were still included in thereported percentages in the descriptive statistics. Alldata was analyzed using Excel 2013 (Version 15.0,Microsoft®).ResultsStudy participantsThe survey was sent to 703 individuals; 484 active, 50emeritus, and 169 resident members of the CanadianSociety of Otolaryngology. At the conclusion of the 6-week study period, 80 surveys were completed. Of these80 responses, 16 were incomplete with no usable data anddiscarded. Of the remaining 64 responses, 10 were fromotolaryngologists who did not perform ear surgery andwere therefore excluded, leaving 54 responses for analysis.Of the 54 study participants, 16 (30 %) were otologists, 21(39 %) were general otolaryngologists, 12 (22 %) werepaediatric otolaryngologists, and 5 (8 %) were trainees(residents and fellows). Figure 1 describes the distributionof the number of years subjects have been in practice.Use of endoscopes in ear surgery practiceAmong the respondents who perform ear surgery, 70 %indicated that they use endoscopes in their practice.Figure 2 describes the number of endoscopic cases thatrespondents have performed. Based on our survey, thereare currently 38 surgeons in Canada who have performedat least one endoscopic ear case, but only 6 surgeons havecompleted more than 50 cases. Of the surgeons who indi-cated that they use an endoscope, 68 % used the endo-scope in the clinic and in the operating room, whilesmaller numbers of surgeons used the endoscope only inclinic (8 %) or only in the operating room (24 %) (Fig. 3).Yong et al. Journal of Otolaryngology - Head and Neck Surgery  (2016) 45:4 Page 2 of 8Cholesteatoma (97 %) and tympanoplasty (71 %) werethe two most common applications for the endoscopeamong respondents (Fig. 4). Ossicular reconstructionwas a more infrequent application, while skull base andstapedotomy were very uncommon uses. Specifically forcholesteatoma surgery, 42 % of surgeons still primarilyuse the microscope with the endoscope as an adjunct,36 % mainly use the endoscope, and 21 % only use theendoscope to check for residual disease at the end of thecase (Fig. 5).Attitude towards endoscopes in ear surgeryThe majority of participants (81 %) recognize a role forthe endoscope in ear surgery. The recognition of a rolefor endoscopes was seen across sub-groups includingthose who do not perform endoscopic surgery (57 %)and those who were well into their practice (65 %).There was no statistically significant difference amongthe sub-groups.Overall, participants had a positive stance on endoscopicear surgery with over 50 % indicating that they were likelyto use endoscopes for ear surgery in their future practice(Table 1). There was a significant difference in the likeli-hood of using endoscopes in the future based on numberof years in practice (p < 0.05), as well as based on numberof endoscopic cases performed to date (p < 0.01). Studyparticipants indicated that they were more inclined to useendoscopes for ear surgery in their future practice if theywere earlier in their practice with 11 to 20 years of experi-ence (OR 2.33, 95 % CI 0.05–11.81) and significantly moreinclined with only 1 to 10 years of experience (OR 18.67,95 % CI 1.88–185.41, p < 0.01) when compared to thosewith 21 years or more of experience. Participants alsoresponded that they would be more likely to use endo-scopes in the future as their endoscopic ear surgery02468101214161820Resident/Fellow  1-10  11-20  21+Number of study participantsYears of practiceFig. 1 Distribution of study participants by number of years in practice02468101214160 1-10 11-20 21-30 31-50 50-100 >100Number of study participants Number of endoscopic cases performed Fig. 2 Distribution of study participants by number of endoscopic ear cases performedYong et al. Journal of Otolaryngology - Head and Neck Surgery  (2016) 45:4 Page 3 of 8experience increased; when compared to those who hadnot performed any endoscopic surgery, participantswere more likely to use an endoscope in the future ifthey had done between 1 and 20 endoscopic cases(OR 2.92, 95 % CI 0.55–15.56) and significantly morelikely to use endoscopes in the future if they haddone more than 20 endoscopic cases (OR 31.29, 95 %CI 1.72–897.14, p < 0.05).Participants also appeared to be more likely to findendoscopic ear surgery easier than microscopic surgeryif they were earlier in their practice and if they had donemore endoscopic ear cases to date, but no significantdifference was found between these sub-groups (Fig. 6).Concerns and challenges surrounding endoscopic earsurgerySingle-handed surgery was the main prevailing concernregarding endoscopic ear surgery (44 %), followed by ef-ficiency/operative time (32 %), technical difficulty (25 %),cost (24 %), and managing bleeding (24 %). No concernsover endoscopic surgery were expressed by 36 % ofparticipants.Advantages of endoscopic ear surgeryReduced recurrence and residual disease rate was themost frequent perceived advantage (59 %), followed byease of teaching trainees (36 %), faster patient recovery(31 %), ease of use (25 %), and less post-operative pain(25 %). No advantage to endoscopic ear surgery overmicroscopic ear surgery was expressed by 17 % ofparticipants.DiscussionThe field of ear surgery has seen rapid technologicaladvancement that has greatly impacted the field ofotology, first with the invention of the operatingmicroscope, and more recently with the emergence ofminimally-invasive endoscopic techniques. Numerousadvantages of the endoscope as compared to themicroscope have been described and it has becomeclear that despite some of the disadvantages of theendoscopic approach, such as technical skill necessaryand increased training requirements, many ear sur-geons recommend a move towards minimally-invasiveendoscopic ear surgery techniques.0% 20% 40% 60% 80% 100%Don't use endoscopesOnly in clinicOnly in the ORBoth in clinic and the ORPercentage of respondentsUsage of endoscopeFig. 3 Usage of endoscopes in otology practice0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%Skull BaseStapedotomyOssicular ReconstructionTympanoplastyCholesteatomaPercentage of endoscopic ear surgeonsType of surgeryFig. 4 Use of the endoscope in specific types of ear surgery, expressed as percentage of surgeons who actively use an endoscope in the operating roomYong et al. Journal of Otolaryngology - Head and Neck Surgery  (2016) 45:4 Page 4 of 8Although the response rate of our study limits ourability to accurately characterize the use of endoscopic earsurgery in Canada, this survey shows an interest amongotolaryngologists in Canada regarding endoscopic ear sur-gery techniques with several surgeons already adoptingand implementing the technique in the operative setting.In addition, there appears to be prevailing optimismregarding the future role of the endoscope in otologic sur-gery, even among those not currently using endoscopes.Based on our survey, the most common application forthe endoscope in the operating room is among cholestea-toma and tympanoplasty procedures. This finding is con-sistent with previous literature which describes reducedcholesteatoma recurrence rates when using an endoscopeand the advantages of minimally-invasive surgery insurgeries such as tympanoplasty [4, 6, 1011]. However,among our respondents it seems that the microscope isstill the instrument of choice in Canada for these proce-dures due to the amount of study participants indicatingthat they use the endoscope only as a adjunct or to checkfor residual disease at the end of a case. While the endo-scope is being used for other purposes such as ossicularreconstruction, skull base surgery, and stapedotomy, itappears that the endoscopic approach in these proceduresis not common practice among the subgroup of Canadianotolaryngologists who responded to the survey.Challenges surrounding the technical skill requiredcontinue to deter some surgeons from using endoscopes[8]. The main concerns regarding the use of endoscopesin ear surgery based on this study were single-handedsurgery, efficiency, cost, and technical difficulty; similarconcerns have been raised in previously published litera-ture, especially the challenge of one-handed surgery andthe initial technical difficulty of implementing and usingendoscopic equipment for the surgeon and operativeteam [6, 8, 11]. Nonetheless, most surgeons indicatedthat they were likely to use endoscopes for ear surgeryin their future practice. In particular, those surgeonswho were earlier in their practice and had performedmore endoscopic ear cases to date were the most enthu-siastic. This supports the concept that surgeons whohave a younger practice and a baseline skill level withendoscopes appear to be more likely to invest resourcesin acquiring endoscopic equipment that may put them0% 20% 40% 60% 80% 100%Microscope primarilyEndoscope primarilyEndoscope at end of case onlyPercentage of cholesteatoma surgeons Use of endoscope Fig. 5 Use of the endoscope during cholesteatoma surgery, expressed as percentage of surgeons who perform cholesteatoma surgeryTable 1Mean Rating (0 – Strongly Disagree, 5 – Strongly Agree) Odds Ratio 95 % Confidence Interval One-Way ANOVAOverall (n = 50) 3.9 - - -Years in Practice p = 0.01421+ (n = 13) 3.2 1 -11-20 (n = 12) 4.1 2.33 0.05–11.811–10 (n = 17) 4.6 18.67 1.88–185.41*Trainee (n = 5) 3.8 N/A -Number of Endoscopic Ear Cases p = 0.00300 (n = 8) 3 11–20 (n = 22) 3.9 2.92 0.55–15.5621+ (n = 12) 4.8 31.29 1.72–897.14*Likelihood of using endoscopes in the future, with responses separated by years of practice and by number of endoscopic ear cases performed*p <0.05Yong et al. Journal of Otolaryngology - Head and Neck Surgery  (2016) 45:4 Page 5 of 8in a better position to overcome some of the concernsthat deter usage of the endoscope in ear surgery. In theauthors' experience, the cost of implementing endo-scopic ear surgery is often quite minimal as most centresare often already well-equipped with endoscopic sinussurgery equipment and already have standard otologicoperative instruments which, when combined, are morethan adequate to get started with the technique.There is a challenging learning curve when transition-ing from the microscope to the endoscope in earsurgery. As expected, this study shows a trend, albeit notstatistically significant, that implies that junior staff andthose with more endoscopic ear experiences find endo-scopic techniques easier than microscopic approaches.This concept has been supported by authors who havedescribed their own endoscopic learning experience andwho have also provided guidance to surgeons who areseeking to implement endoscopic techniques into theirpractice for the first time [8, 11, 12]. Further investmentin endoscopic training programs may allow moresurgeons to overcome the hurdles that currently pre-clude them from incorporating endoscopes into their earsurgery practice.Once some of the initial technical and learning diffi-culties of endoscopic ear surgery can be overcome, manyauthors advocate that the benefits of using the endo-scope are multifaceted [2, 6, 8, 11]. The proposed bene-fits of endoscopic surgery based on current literaturealign well with the views of Canadian otolaryngologists,particularly with respect to the reduced rate of residualor recurrent cholesteatoma and the ease of obtainingbetter surgical visualization [6, 7]. Other advantages suchas reduced post-operative pain and faster patient recov-ery are also in agreement with literature articles studyingthese outcomes in ear surgery patients [10, 12, 13].There was considerable agreement among respon-dents that endoscopes have a role to play in thefuture of ear surgery. The fact that there was no sig-nificant difference in these results based on eithernumber of years in practice or experience with theendoscope suggests that there is a general acceptanceand support for the use of endoscopes in ear surgeryamong the subgroup of Canadian otolaryngologistsparticipating in the survey. This finding supportsprevious literature which promotes the use of endo-scopes in the field of ear surgery [6–8, 10–11, 14],012345671-10 11-20 21+Number of study participantsYears of practiceHarder thanMicroscopic SurgeryComparable toMicroscopic SurgeryEasier than MicroscopicSurgery012345678910 1-20  21+Number of study participantsNumber of endoscopic ear cases performedHarder thanMicroscopic SurgeryComparable toMicroscopic SurgeryEasier than MicroscopicSurgeryFig. 6 Overall learning experience with endoscopic ear surgery when compared to microscopic surgery, plotted against number of years in practiceand against number of endoscopic ear cases performedYong et al. Journal of Otolaryngology - Head and Neck Surgery  (2016) 45:4 Page 6 of 8and, at the very least, indicates that investing furtherresources into teaching and promoting the use ofendoscopes will likely be met with enthusiasm.This study has a number of limitations. Survey data wascollected in a non-randomized manner and was entirelydependent on the voluntary response rate among otolar-yngologists who were subscribed to the Canadian Societyof Otolaryngology listserv. The survey was sent to 703Canadian Society of Otolaryngology members and while64 responded, only 54 actually performed ear surgery intheir current practice. Although the response rate was lowat 9 %, one must take into account the current subspecia-lized nature of otolaryngology in Canada within bothcommunity and academic environments. Many Canadianotolaryngologists with interests in subspecialty fields suchas rhinology/sinus, head and neck, and facial plastics likelyignored the email given that ear surgery is not within theirscope of current practice. The response rate, althoughquite low, is therefore still difficult to fully interpret.Among the active members of the Canadian Society ofOtolaryngology, 36 are fellowship trained in otology and18 have an interest in otology without formal fellowshiptraining. It may not be coincidence that this sum equals54, which is the exact number of survey responses ana-lyzed for this study. This survey may therefore be biasedtowards surgeons with a subspecialty interest in otologyand likely a practice with higher volumes of more complexotologic surgery. Accordingly, the results need to beinterpreted within that context and not extrapolated tothe wider otolaryngology community within Canada. Thesmall response rate also meant that in cases where sub-group analysis was necessary, some sample sizes were toosmall to conduct rigorous statistical analyses. Finally, theamount of trainees completing the survey was too smallto be included in rigorous statistical analysis calculationsand, thus, was only included in the graphical statistics.ConclusionThis is the first study aimed toward comprehensivelycharacterizing the current state of endoscopic ear surgeryin Canada. Patterns of endoscope use, attitudes, learningexperiences and perceived advantages and challengesregarding endoscopic ear surgery were documented andquantified among Canadian otolaryngologists. Althoughcare should be taken when generalizing these findings to allCanadian otolaryngologists considering the aforementionedstudy limitations, a number of valuable overall assessmentscan be offered. Findings show that a considerable numberof ear surgeons currently use endoscopes to some capacityin their practice and that, despite some reservations, thereis an overall enthusiasm for the endoscopic approach tootologic surgery. Furthermore, there is a general feelingamong survey respondents that endoscopes will likely havea role to play in the future of otologic surgery. Given thecontinuous improvement in endoscopic technology andincreasing acceptance of endoscopic ear surgery, invest-ment in training courses and guidance for those looking tostart or advance their use of the endoscope in their practicewill be vital in the years to come.Ethics approvalEthics approval was obtained from the UBC BehaviouralResearch Ethics Board (ID H14-03499) and consent wasobtained from survey participants by email using theCSO listserv.Additional fileAdditional file 1: Endoscopic ear surgery in Canada survey.(DOC 25 kb)AbbreviationsCSO: Canadian Society of Otolaryngology; OR: Odds ratio; ANOVA: Analysis ofvariance.Competing interestsThe authors declare that they have no competing interests.Authors’ contributionsJL conceived of the study, facilitated survey administration and data-gathering,and oversaw editing of the manuscript. TM assisted with data analysis andcontributed to drafting the manuscript. MY facilitated study design and surveyadministration, conducted raw data processing and statistical analysis, andcontributed to drafting the manuscript. All authors read and approved the finalmanuscript.AcknowledgementsWe would like to thank Ms. Donna Humphrey from the administrative staffat the Canadian Society of Otolaryngology for her assistance inadministering the survey.Author details1University of British Columbia, Division of Otolaryngology – Head and NeckSurgery, 4th Floor, 2775 Laurel Street, Vancouver General Hospital,Vancouver, BC V5Z 1 M9, Canada. 2McGill University, Department ofOtolaryngology – Head and Neck Surgery, Royal Victoria Hospital - D05.5712,1001 Décarie Boul, Montreal H4A 3 J1, Canada. 3University of BritishColumbia, Division of Otolaryngology – Head and Neck Surgery, ENT Clinic,1081 Burrard Street, St. Paul’s Hospital, Vancouver, BC V6Z 1Y6, Canada.Received: 24 October 2015 Accepted: 10 January 2016References1. Yung MM. The use of rigid endoscopes in cholesteatoma surgery.J Laryngol Otol. 1994;108(4):307–9.2. El-Meselaty K, Badr-El-Dine M, Mourad M, Darweesh R. Endoscope affectsdecision making in cholesteatoma surgery. Otolaryngol Head Neck Surg.2003;129(5):490–6.3. Lade H, Choudhary SR, Vashishth A. Endoscopic vs microscopicmyringoplasty: a different perspective. Eur Arch Otorhinolaryngol.2014;271(7):1897–902.4. Marchioni D, Villari D, Mattioli F, Alicandri-Ciufelli M, Piccinini A, Presutti L.Endoscopic management of attic cholesteatoma: a single-institutionexperience. Otolaryngol Clin N Am. 2013;46(2):201–9.5. Badr-el-Dine M, James EL, Panetti G, Marchioni D, Presutti L, Noqueira JF.Instrumentation and technologies in endoscopic ear surgery.Otolaryngol Clin N Am. 2013;46(2):211–25.6. Badr-el-Dine M. Value of ear endoscopy in cholesteatoma surgery.Otol Neurotol. 2002;23:631–5.Yong et al. Journal of Otolaryngology - Head and Neck Surgery  (2016) 45:4 Page 7 of 87. Ayache S, Tramier B, Strunski V. Otoendoscopy in cholesteatoma surgeryof the middle ear: what benefits can be expected? Otol Neurotol.2008;29(8):1085–90.8. Pothier DD. Introducing endoscopic ear surgery into practice. Otolaryngol ClinN Am. 2013;46(2):245–55.9. Kozin ED, Lehmann A, Carter M, Hight E, Cohen M, Nakajima HH, et al.Thermal effects of endoscopy in a human temporal bone model:implications for endoscopic ear surgery. Laryngoscope. 2014;124(8):E322–9.10. Tarabichi M. Endoscopic management of cholesteatoma: long-term results.Otolaryngol Head Neck Surg. 2000;122:874–81.11. Youssef TF, Poe DS. Endoscope-assisted second-stage tympanomastoidectomy.Laryngoscope. 1997;107:1341–4.12. James AL. Endoscopic middle ear surgery in children. Otolaryngol Clin NAm. 2013;46:233–44.13. Shaia WT, Diaz RC. Evaluation in surgical management of superiorcanal dehiscence syndrome. Curr Opin Otolaryngol Head Neck Surg.2013;21(5):497–502.14. Presutti L, Nogueira JF, Alicandri-Ciufelli M, Marchioni D. Beyond the middleear: endoscopic surgical anatomy and approaches to inner ear and lateralskull base. Otolaryngol Clin N Am. 2013;46:189–200.•  We accept pre-submission inquiries •  Our selector tool helps you to find the most relevant journal•  We provide round the clock customer support •  Convenient online submission•  Thorough peer review•  Inclusion in PubMed and all major indexing services •  Maximum visibility for your researchSubmit your manuscript atwww.biomedcentral.com/submitSubmit your next manuscript to BioMed Central and we will help you at every step:Yong et al. Journal of Otolaryngology - Head and Neck Surgery  (2016) 45:4 Page 8 of 8

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