Efficacy of a Novel Continuous Irrigation Mode in Endoscopic Ear Surgery for External Auditory Canal Cholesteatoma

Efficacy of a Novel Continuous Irrigation Mode in Endoscopic Ear Surgery for External Auditory Canal Cholesteatoma | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Efficacy of a Novel Continuous Irrigation Mode in Endoscopic Ear Surgery for External Auditory Canal Cholesteatoma Nan Zeng, Qiong Yang, Lue Zhang, Jing Hu, Mingxing Tang, Shuo Li, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5766579/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose To evaluate the application and efficacy of a novel continuous irrigation mode in endoscopic ear surgery for external auditory canal cholesteatoma (EACC). Methods A retrospective analysis of 66 patients undergoing surgery for EACC at Shenzhen Nanshan People’s Hospital (January 2022 – December 2023) was conducted. Patients were divided into two groups of 33 each: continuous irrigation mode (experimental) and non-irrigation mode (control). Key metrics included intraoperative lens cleaning frequency, operation duration, postoperative complications, epithelialization time(defined as the external auditory canal having no exudate and the granulation tissue on its surface being covered by normal skin tissue), hearing improvement,cleaning frequency within 6 months, and recurrence rate of external auditory canal cholesteatoma . Results The experimental group demonstrated shorter operation time, fewer lens cleanings, reduced complication rates, faster epithelialization, and lower postoperative cleaning frequency (P 0.05). Conclusion The novel continuous irrigation mode significantly enhances surgical efficiency, safety, and outcomes in EACC management, with potential for broad application in primary healthcare settings. Biological sciences/Biological techniques Health sciences/Diseases Health sciences/Health care Health sciences/Medical research Continuous Irrigating Mode Endoscopic Ear Surgery External Auditory Canal Cholesteatoma Figures Figure 1 Figure 2 INTRODUCTION External Auditory Canal Cholesteatoma (EACC) is an external ear disease caused by the aggregation of desquamated epithelial masses in the external auditory canal. This disease is relatively rare and more common in adults. The etiology and pathogenesis of EACC are still under exploration. If left untreated, it may lead to obstruction of the external auditory canal, infections, and invasion of the mastoid and middle ear cavities, resulting in progressive hearing loss and damage to the bone structure[ 1 ]. In the management of EACC, a tailored approach is advocated, necessitating the selection of an appropriate treatment modality based on the extent, severity, and staging of the patient's lesion, in conjunction with the patient's preferences.The principle of treatment is to remove the cholesteatoma in the external auditory canal as completely as possible while preserving healthy external auditory canal skin and bone [ 2 ]. In recent years, endoscopic ear surgery(EES) has emerged as a preferred modality in the management of EACC, owing to its high-definition visualization capabilities. The endoscope can pass through the narrow ear canal to increase the surgical field of vision, improve the surgical field clarity, and observe tissue from multiple angles at close range. EES has thus become increasingly integral to the diagnostic and therapeutic armamentarium for ear pathologies, offering superior visualization of the intricate middle ear anatomy and facilitating more precise surgical interventions. Despite the significant advancements in EES, several intrinsic limitations persist. The procedure often requires single-handed manipulation, which can impede effective hemostasis and control of the surgical field. Additionally, the two-dimensional perspective may restrict the depth perception crucial for intricate ear surgeries. Intraoperative bleeding and lens fogging can significantly obscure visualization, while the heat generated by the light source poses a risk of thermal injury to delicate middle ear structures[ 3 ]. These factors collectively impose certain constraints on the broader adoption and evolution of EES in otological practice [ 4 – 6 ]. Continuous Irrigating Mode for Endoscopic Ear Surgery (CIM-EES) is an innovative surgical approach initially proposed by Chinese scholar Liao Hua[ 7 ], drawing on the characteristics of endoscopy and referencing surgical modalities used in gynecological balloon pump procedures and urological bladder surgeries. This method has been further refined and popularized by Hou Zhaohui and Yu Youjun[ 8 ], addressing specific issues and shortcomings associated with traditional endoscopic ear surgery. CIM-EES has been designed to enhance clarity and smoothness in the endoscopic ear surgery process, thereby improving surgical outcomes and patient safety. This study delves into the application of the self-developed continuous irrigation mode in endoscopic surgery for EACC, highlighting the significance of CIM-EES in advancing the field of otological surgery. Materials and Methods A. Research Subjects A retrospective analysis included 66 EACC patients (January 2022 – December 2023) undergoing general anesthesia at Shenzhen Nanshan People’s Hospital. Patients were divided into two groups of 33 each: continuous irrigation mode (experimental) and non-irrigation mode (control). Prior to surgery, all patients underwent comprehensive audiological assessments, endoscopic evaluations, and temporal bone CT scans, performed by the same senior attending physician. The study's inclusion criteria were as follows: ①Patients could not endure the treatment in the outpatient setting through ear endoscopic; ② The age range was between 6 and 70 years; ③ EACC was classified as stages I and II according to Shin's classification [ 9 ]; ④ The surgery was conducted entirely under endoscopic visualization.” - “Exclusion criteria included: ① Patients with central nervous system disorders; ② Patients with coagulopathy; ③Patients with immune system disorders; ④ Patients with abnormal liver or kidney function; ⑤ Patients with malignant tumors; ⑥ Patients with psychiatric disorders; ⑦ Patients who were intolerant of surgery or had contraindications for surgical intervention. The study adhered to the ethical standards of the Helsinki Declaration, and all participants provided written informed consent prior to undergoing any procedures or operations(Ethical approval number:LW-2024-035). B. Production and Use of Continuous Irrigation Mode 1) Materials The assembly requires one disposable infusion set, two infusion extension tubes, one disposable long needle with a diameter of 1.2mm, one disposable suction catheter with a diameter of 4mm, and 3000ml bags of physiological sodium chloride solution at a concentration of 0.9% (27g/bag). 2)Assembly Method As depicted in Fig. 1 A, the disposable infusion set(4→) and the two infusion extension tubes(2/3→) are connected in tandem. The sharp end of the infusion set is introduced into the physiological sodium chloride solution༈6→༉from Fig. 1 C, while one end of an infusion extension tube is attached to the disposable needle༈1→༉. The connections should be secured with medical-grade adhesive to prevent fluid leakage. As illustrated in Fig. 1 B, a segment of the suction catheter༈5→༉, approximately 3–4 cm in length, is positioned at the front end of a 0° endoscope (diameter 3mm, Karl Storz, Germany). The disposable needle from Fig. 1 A is then inserted through the gap between the suction catheter and the endoscope. The infusion set tube is subsequently attached to a power control system (Medtronic, USA) as illustrated in Fig. 1 C, with the irrigation mode being activated and deactivated using a foot pedal for precise control. C. Surgical Steps All procedures were performed by the same seasoned chief surgeon, with comprehensive video documentation of each surgical step. Patients were administered general anesthesia. After completion of disinfection and draping, the irrigation device was connected, and a 3000ml bag of 0.9% physiological sodium chloride solution (27g/bag) was prepared. The irrigation control foot pedal was positioned at the assistant's footrest. The surgeon held the endoscope with the left hand and manipulated the surgical instruments with the right. The assistant also ensured the suction device was placed adjacent to the saline collection bag, external to the auricle, and adjusted it as necessary to maintain unobstructed operation. In the experimental group, the irrigation mode was initiated upon endoscope introduction, marking the commencement of surgery. Both groups proceeded with surgery according to standard protocols, with the surgeon adjusting the depth of the endoscope in response to the surgical field exposure. Upon completion of the surgery, the ear canal was treated with antibiotic ointment and hemostatic sponges. D.Outcome Metrics All patients had their surgical procedures documented with video recordings. They were discharged the day following surgery and were prescribed a 5-day course of oral antibiotics. Ear endoscopies were scheduled on the 14th, 21st, and 28th postoperative days, as well as at 3 and 6 months post-surgery to assess the status of the external auditory canal flap and the tympanic membrane. Pure tone audiometry was conducted 6 months after the surgery. Key metrics included intraoperative lens cleaning frequency, operation duration, postoperative complications, epithelialization time(defined as the external auditory canal having no exudate and the granulation tissue on its surface being covered by normal skin tissue), hearing improvement,cleaning frequency within 6 months, and recurrence rate of external auditory canal cholesteatoma . E. Statistical Methods Data were analyzed using SPSS v26. Quantitative data that were normally distributed are presented as means ± standard deviations, and independent samples t-tests were employed for comparing group means. Categorical data were compared between groups using chi-square tests. A p-value of less than 0.05 was considered to indicate statistical significance. Results A. General results Out of a total of 66 patients, all presented with unilateral cases. The experimental group comprised 15 males and 18 females with a mean age of (21.45 ± 3.70) years, while the control group included 21 males and 12 females with a mean age of (23.52 ± 3.89) years. In the control group, 12.1% (4/33) of the patients experienced varying degrees of intraoperative complications. Postoperatively, there have been no instances of recurrence of external auditory canal cholesteatoma or secondary middle ear cholesteatoma at over 1 year of follow-up. Two patients in the experimental group and four in the control group developed fungal external otitis, which subsequently resolved with conservative management. B. Significant Reduction in Complication Incidence in the Experimental Group Among the 66 patients enrolled in the study, none experienced severe complications such as facial paralysis, hypogeusia, or vertigo. However, within the control group, two patients sustained intraoperative tears of the tympanic membrane. These tears were managed with the application of antibiotic gelatin sponge and resolved spontaneously within two weeks postoperatively. Additionally, one patient in the control group had exposure of bare bone in the ear canal, and another developed mild stenosis of the ear canal. In contrast, the experimental group demonstrated a significantly lower rate of complications with 0%. The statistical analysis revealed p<0.05, denoting a statistically significant difference in complication rates between the two groups. C. The intraoperative lens cleaning frequency and operation duration were significantly shortened in the experimental group Through the analysis of the surgical video, the frequency of lens cleaning and operation duration of the two groups were counted, and the number of lens cleaning and operation duration of the experimental group were significantly shortened, ρ < 0.05. The difference was statistically significant, as shown in Table 1 . Table 1 The intraoperative lens cleaning frequency and operation duration were compared in the experimental group Group Lens cleaning frequency Operation duration (minutes) experimental group 3.24 ± 0.71 10.93 ± 1.20 control group 26.67 ± 4.72 24.65 ± 3.48 t 62.63 20.18 \(\:{\rho\:}\) 0.000 0.000 D. Postoperative Ear Canal Epithelialization Time Was Reduced On the 14th postoperative day, the external auditory canals of all patients were endoscopically inspected to remove any residual hemostatic sponges and to assess the condition of the surgical cavity and the tympanic membrane. At the initial postoperative review, the tympanic membranes of all 66 patients were found to be intact, while the external auditory canal epithelium exhibited varying degrees of erythema, edema, and serous discharge. Subsequent ear endoscopies were scheduled at 21, 28 days, and at 3 and 6 months postoperatively to document the status of the skin and tympanic membrane within the external auditory canal. Based on the condition of the external ear canal skin, the frequency of follow-up visits was adjusted, and the number of ear canal cleanings within the first 6 postoperative months was recorded. Comparative analysis of these data revealed that the experimental group had a shorter postoperative ear canal epithelialization time and a significantly reduced number of ear canal cleanings within 6 months compared to the control group. For detailed statistics, refer to Table 2 . Table 2 The epithelialization time and frequency of ear canal cleaning were compared in the experimental group Group Ear canal epithelialization time (days) Frequency of ear canal cleaning (times) experimental group 16.30 ± 2.27 1.76 ± 0.66 control group 26.64 ± 11.56 4.73 ± 1.31 t 23.23 25.68 \(\:{\rho\:}\) 0.000 0.000 E. No Significant Difference in Postoperative Hearing Improvement Between Groups The average Air-Bone Gap (ABG) at frequencies of 0.5 kHz, 1 kHz, 2 kHz, and 4 kHz was calculated for each patient. In the experimental group, the preoperative ABG was (14.53 ± 3.86) dB HL, which reduced to a postoperative ABG of (3.20 ± 1.90) dB HL. For the control group, the preoperative ABG was (18.83 ± 8.56) dB HL, and the postoperative ABG was (3.00 ± 1.96) dB HL. Statistical comparison of the two groups' data revealed a p > 0.05, indicating no significant difference in postoperative hearing improvement between the experimental and control groups. Discussion A.Advantages of CIM-EES for EACC The advent of Continuous Irrigating Mode for Endoscopic Ear Surgery (CIM-EES) has been timely in addressing the challenges associated with EACC. Patients with this condition often present with substantial keratin debris obstructing the ear canal, along with granulation tissue hyperplasia and bone destruction [ 10 ]. Traditional endoscopic surgery can pose risks to the external auditory canal flap, the mastoid segment of the facial nerve, or the tympanic membrane due to bleeding from granulation tissue, potentially leading to postoperative complications such as ear canal scarring, facial nerve injury, or tympanic membrane perforation [ 11 – 16 ]. CIM-EES facilitates the formation of a water flow within the intraoperative cavity under controlled pressure for outward one-way circulation. Blood seepage and bone residue, which are common during surgery, are flushed out of the ear canal by this pressured water flow. This process helps maintain a clear endoscopic field of view and intraoperative cavity, enhancing the convenience and fluency of the surgical procedure, and increasing surgical safety [ 17 ]. Currently, CIM-EES has been applied in endoscopic tympanic membrane repair, tympanoplasty, middle ear cholesteatoma surgery, facial nerve decompression, and transmeatal-promontory acoustic neuroma resection, among others [ 8 ]. The purpose of this study was to investigate the application of CIM-EES in EES for EACC. The results showed that the frequency of intraoperative lens cleaning (3.24 ± 0.71 times), operation duration (10.93 ± 1.20 minutes), the incidence of complication (0), epithelialization time of external ear canal (16.30 ± 2.27 days) ,and postoperative cleaning times(1.76 ± 0.66 times) in experimental group were significantly lower than those in control group. Continuous irrigating mode effectively reduces intraoperative lens contamination and surgical interruption by removing bleeding and cholestatoma epithelium in real time, significantly improving surgical fluency and efficiency. This technical advantage is particularly important for patients with cholestatoma of the external auditory canal, as a clear field of view is essential for complete removal of cholestatoma and avoidance of residual cholestatoma (Fig. 2 ). In addition, the clear surgical field directly separated the lesion from the ear canal epithelium, tympanic membrane, and facial nerve, reducing the possibility of intraoperative damage to important structures and improving the accuracy of the operator's operation. This improvement is especially suitable for the removal of cholesteatoma of the external ear meatus which requires very high surgical field. During the operation, the high-flow lavage liquid directly cleared the cholestatoma epithelium attached to the skin surface of the external ear canal and the surface of the eardrum, reducing the stimulation of the ear canal skin and the eardrum, reducing the risk of eardrum tearing and the risk of postoperative ear canal skin swelling and scar stenosis. The skin of the external auditory canal is well protected and can quickly restore epithelialization, and greatly facilitating the recovery and follow-up management of patients. B. Structural advantages of self-developed irrigation mode The widely used irrigation devices in the domestic market are associated with higher costs, which may limit their accessibility and application in some settings.Another drawback of the existing irrigation devices is their limited compatibility with different brands of endoscopes. This lack of versatility can pose challenges in clinical practice, as hospitals often use endoscopes from various manufacturers. By highlighting these differences and advantages, we aim to provide a stronger context for the superiority of our CIM-EES approach. The novel continuous irrigation mode, as utilized in this study, offers structural advantages that address the high costs associated with commercially available irrigation devices and equipment. This device has been previously applied by domestic scholars in endoscopic tympanic cholesteatoma surgery, demonstrating its practicality [ 18 ]. Constructed from basic medical disposables, the device is characterized by its low cost and ease of assembly. The design emphasizes continuous perfusion and endoscope lens cleaning through a secure connection between the disposable needle and the endoscope's front end, ensuring a clear surgical field and preventing fluid residue accumulation in front of the lens sheath and body. By integrating the perfusion line into the Medtronic power system, we have omitted the need for a pressure pump, allowing for foot-controlled perfusion mode activation and deactivation. This self-made device caters to the needs of primary hospitals and resource-limited settings, providing a cost-effective solution for ear surgery. The pressurization system of our self-made device leverages the control valve from a standard power system, maintaining a stable perfusion speed while avoiding the high costs associated with complex pump systems. In this study, a flow rate of 0.2 L/min was found to be effective for clearing blood and debris from the surgical field, eliminating the need for a high-precision pressure controller. This innovative design holds significant value for primary healthcare institutions. Despite the CIM-EES model's clear benefits in enhancing surgical efficiency and safety, several challenges accompany its implementation. Surgeons must adjust to the perfusion velocity and pressure to prevent damage to the ear canal flap and tympanic membrane from the force of the perfusion fluid. Our self-made devices, assembled from various simple consumables, currently lack a uniform standard, which may lead to variability in their performance across different medical institutions. Additionally, the performance and stability of these devices in long-term or high-frequency surgical procedures require further validation. The manufacturing and installation of perfusion devices also necessitate a certain level of proficiency, potentially hindering their adoption in primary hospitals. Future improvements in device design and standardized operating procedures could enhance the technology's ease of use and adaptability. C. Limitations and Future Directions of This Study This study represents a retrospective analysis with a limited number of cases and a short postoperative follow-up period, which restricts the comprehensive assessment of long-term outcomes. Future multi-center, large-sample prospective studies will be instrumental in further validating the applicability of the CIM-EES model across a range of ear diseases. Moreover, integrating intelligent equipment to optimize the perfusion mode, including precise pressure control and real-time field of view analysis, may lead to further enhancements in the operating experience and clinical outcomes of endoscopic ear surgery. Conclusion The present study demonstrates that the utilization of a novel continuous irrigation mode in endoscopic surgery for external auditory meatus cholesteatoma yields significant benefits. It not only substantially reduced the operative duration and the frequency of intraoperative lens cleaning and visual obscuration but also lowered the incidence of postoperative complications and recurrence rates. This approach is characterized by its ease of operation, safety, and efficacy, making it a viable candidate for widespread adoption, particularly in primary healthcare settings. Looking ahead, the integration of intelligent equipment to refine perfusion modalities has the potential to enhance surgical efficiency and patient outcomes, offering innovative insights into the advancement of ear endoscopic surgical techniques. Abbreviations ABG air-bone gap EACC external auditory canal cholesteatoma EES endoscopic ear surgery CIM-EES continuous irrigating mode for endoscopic ear surgery Declarations Source of financial support in the form of grants: This study was supported by grants from the Nanshan District Medical Key Discipline Construction Financial Support Project. Authors' contributions: Nan Zeng was responsible for designing the theme. Qiong Yang, Lue Zhang and Jing Hu were responsible for data collection and surgical procedures.Mingxing Tang and Shuo Li were responsible for data statistics and analysis. Because this research is designed and carried out under the guidance of Shang Yan, he is the correspondence author. Conflict of Interest Statement The authors declare that they have no conflicts of interest. Ethics approval and consent to participate：Ethics Committee approval was obtained. Consent for publication: Written informed consent for publication of their clinical details and clinical mages was obtained from the patient. Availability of data and materials: The datasets used and analysed during the current study are available from the corresponding author on reasonable request via the email [email protected] . Competing interests: The authors declare that they have no competing interests Acknowledgements: Thank every author for his work. Declaration of Figures Authenticity: All figures submitted have been created by the authors who confirm that the images are original with no duplication and have not been previously published in whole or in part. References Qian, M. F. et al. Clinical characteristics and treatment of external auditory canal cholesteatoma. J. Audiol. Speech Pathol. 24 (02), 149–152 (2016, March). HUANG J., LI Y., PENG T., FENG B. May). Current Status of Diagnosis and Treatment of External Auditory Canal Cholesteatoma. Chin. J. Otorhinolaryngol. , 18 (05), 957–961. (2020). Marchioni, D. et al. Complications in Endoscopic Ear Surgery. Otol Neurotol . 39 (8), 1012–1017 (2018). Stern Shavit, S., Sharma, R. K., Chern, A. & Golub, J. S. Pearls and Pitfalls in Endoscopic Ear Surgery. Otolaryngol. Clin. North. Am. 54 (1), 201–209 (2021, February). Kozin, E. D. et al. Thermal effects of endoscopy in a human temporal bone model: implications for endoscopic ear surgery. Laryngoscope 124 (8), E332–E339 (2014, August). Mitchell, S. & Coulson, C. Endoscopic ear surgery: a hot topic? J. Laryngol Otol . 131 (2), 117–122 (2017, February). Liao, H. et al. June). A novel continuous irrigating endoscopic ear surgery mode for Type I tynpanoplasty. J. Audiol. Speech Pathol. 27 (6), 615–618 (2019). LIAO H., YU Y., HOU Z. Continuous Irrigation in Endoscopic Ear Surgery. Chin. J. Otology , 19 (2), 192–197. (2021), February. Shin, S. H., Shim, J. H. & Lee, H. K. Classification of external auditory canal cholesteatoma by computed tomography. Clin. Exp. Otorhinolaryngol. 3 (1), 24–26 (2010, March). Bonding, P. & Ravn, T. Primary cholesteatoma of the external auditory canal: is the epithelial migration defective? Otol Neurotol . 29 (3), 334–338 (2008). Nogueira, J. F., de Querido, S. L. F., Gonçalves da Silva Leite, R. & da Costa, J. T. Future of Endoscopic Ear Surgery. Otolaryngol Clin North Am ., 54(1), 221–231. (2021), February. Naim, R., Sadick, H., Schafer, C. & Hormann, K. External auditory canal cholesteatoma: analysis of the integrity of the tissue structure. Int. J. Mol. Med. 14 (4), 601–604 (2004, April). Zhang, Y. et al. December). External auditory canal cholesteatoma in children: clinical manifestations. Eur. Arch. Otorhinolaryngol. 281 (12), 6645–6651 (2024). Heilbrun, M. E. et al. External auditory canal cholesteatoma: clinical and imaging spectrum. AJNR Am. J. Neuroradiol. 24 (4), 751–756 (2003, April). Zhang, X. L. & Jin, L. Clinical Analysis of 36 Cases with External Auditory Canal Cholesteatoma. Surg. Res. New. Techniques . 10 (04), 273–276 (2021, April). Zhou, N., Li, L. B. & Lin, L. Clinical Characteristics and Surgical Treatment of Types II-IV External Auditory Canal Cholesteatoma. J. Clin. Otolaryngol. Head Neck Surg. 30 (16), 1287–1289 (2016, August). Liao, H. et al. Expert Consensus on Continuous Irrigation Mode in Endoscopic Otologic Surgery. J. Clin. Otolaryngol. Head Neck Surg. 38 (02), 93–97 (2024, February). Li, Y. et al. November). Application of Self-made Continuous Irrigation Device in Endoscopic Surgery for Supratympanic Cholesteatoma. Chin. J. Otorhinolaryngol. Head Neck Surg. 57 (11), 1319–1322 (2022). Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5766579","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":401109124,"identity":"673fdc0b-a302-4021-b192-c33026a40460","order_by":0,"name":"Nan Zeng","email":"","orcid":"","institution":"Shenzhen Nanshan People’s Hospital","correspondingAuthor":false,"prefix":"","firstName":"Nan","middleName":"","lastName":"Zeng","suffix":""},{"id":401109125,"identity":"26ae7516-7362-4285-a311-1071f1a9db70","order_by":1,"name":"Qiong Yang","email":"","orcid":"","institution":"Shenzhen Nanshan People’s Hospital","correspondingAuthor":false,"prefix":"","firstName":"Qiong","middleName":"","lastName":"Yang","suffix":""},{"id":401109126,"identity":"bc2bdc03-9543-4da6-934a-15f2aaae6276","order_by":2,"name":"Lue Zhang","email":"","orcid":"","institution":"Shenzhen Nanshan People’s Hospital","correspondingAuthor":false,"prefix":"","firstName":"Lue","middleName":"","lastName":"Zhang","suffix":""},{"id":401109128,"identity":"c3a08749-00f5-4a6f-a4d9-f4cd01d8db11","order_by":3,"name":"Jing Hu","email":"","orcid":"","institution":"Shenzhen Nanshan People’s Hospital","correspondingAuthor":false,"prefix":"","firstName":"Jing","middleName":"","lastName":"Hu","suffix":""},{"id":401109132,"identity":"e419e7ce-a304-4fd0-8621-3702d6a5e7cf","order_by":4,"name":"Mingxing Tang","email":"","orcid":"","institution":"Shenzhen Nanshan People’s Hospital","correspondingAuthor":false,"prefix":"","firstName":"Mingxing","middleName":"","lastName":"Tang","suffix":""},{"id":401109133,"identity":"f0350e15-6f1f-45a8-9342-a9960f7b3659","order_by":5,"name":"Shuo Li","email":"","orcid":"","institution":"Shenzhen Nanshan People’s Hospital","correspondingAuthor":false,"prefix":"","firstName":"Shuo","middleName":"","lastName":"Li","suffix":""},{"id":401109134,"identity":"b1ab9953-ba71-4941-862e-8afd4917c675","order_by":6,"name":"Shang Yan","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA20lEQVRIiWNgGAWjYFACHhAhIcfG3nzgwIcfxGuxMebjOZZ4cGYP8VrSEuUkfIwPc7ARocHg/NmDnwt+HU5gk+D5cBioX55f7AABLTfykqVn9h3OY5Pu3XC4wILBcObsBEJaeAykeXsOF7PJnN1weAYPQ4LBbUJazp8x/g3UktgmkfPgMA8bMVoO5JhJ8/xIA2lhIE6L5I0cM2veBhtjNp5jBsBAliDsFz6gw27z/JGQk29vfvzhww8beX5pAloUDgAJxjY4XwK/chCQbwCRfwgrHAWjYBSMghEMAKU8SNiQ4LTXAAAAAElFTkSuQmCC","orcid":"","institution":"Shenzhen Children’s Hospital","correspondingAuthor":true,"prefix":"","firstName":"Shang","middleName":"","lastName":"Yan","suffix":""}],"badges":[],"createdAt":"2025-01-05 07:38:05","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5766579/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5766579/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":73865366,"identity":"7aef5cf6-cbaf-4c65-8faf-6db296efed99","added_by":"auto","created_at":"2025-01-15 11:44:57","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1465758,"visible":true,"origin":"","legend":"\u003cp\u003eProduction of Continuous Irrigation Mode.1→:the disposable needle; 2/3→:the infusion extension tubes; 4→:the disposable infusion set; 5→:a segment of the suction catheter;6→:the physiological sodium chloride solution.\u003c/p\u003e","description":"","filename":"fig1.tif.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5766579/v1/0ed313da87d1217325130ca0.jpg"},{"id":73867729,"identity":"ea252aac-9d74-4978-8caf-62828c2c7248","added_by":"auto","created_at":"2025-01-15 12:00:57","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":187688,"visible":true,"origin":"","legend":"\u003cp\u003eDuring the operation in CIM-EES, the cholesteatoma epithelium and its space with the skin can be clearly seen.\u003c/p\u003e","description":"","filename":"fig2.tif.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5766579/v1/856c4bf52a56520e1abc2ddd.jpg"},{"id":75304644,"identity":"1d5edcc7-9738-4b6c-ad99-e4421955da26","added_by":"auto","created_at":"2025-02-03 08:09:23","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2360566,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5766579/v1/b30ee3ea-6a2e-414e-8f21-b9634c24c6a1.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Efficacy of a Novel Continuous Irrigation Mode in Endoscopic Ear Surgery for External Auditory Canal Cholesteatoma","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eExternal Auditory Canal Cholesteatoma (EACC) is an external ear disease caused by the aggregation of desquamated epithelial masses in the external auditory canal. This disease is relatively rare and more common in adults. The etiology and pathogenesis of EACC are still under exploration. If left untreated, it may lead to obstruction of the external auditory canal, infections, and invasion of the mastoid and middle ear cavities, resulting in progressive hearing loss and damage to the bone structure[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In the management of EACC, a tailored approach is advocated, necessitating the selection of an appropriate treatment modality based on the extent, severity, and staging of the patient's lesion, in conjunction with the patient's preferences.The principle of treatment is to remove the cholesteatoma in the external auditory canal as completely as possible while preserving healthy external auditory canal skin and bone [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. In recent years, endoscopic ear surgery(EES) has emerged as a preferred modality in the management of EACC, owing to its high-definition visualization capabilities. The endoscope can pass through the narrow ear canal to increase the surgical field of vision, improve the surgical field clarity, and observe tissue from multiple angles at close range. EES has thus become increasingly integral to the diagnostic and therapeutic armamentarium for ear pathologies, offering superior visualization of the intricate middle ear anatomy and facilitating more precise surgical interventions.\u003c/p\u003e \u003cp\u003eDespite the significant advancements in EES, several intrinsic limitations persist. The procedure often requires single-handed manipulation, which can impede effective hemostasis and control of the surgical field. Additionally, the two-dimensional perspective may restrict the depth perception crucial for intricate ear surgeries. Intraoperative bleeding and lens fogging can significantly obscure visualization, while the heat generated by the light source poses a risk of thermal injury to delicate middle ear structures[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. These factors collectively impose certain constraints on the broader adoption and evolution of EES in otological practice [\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eContinuous Irrigating Mode for Endoscopic Ear Surgery (CIM-EES) is an innovative surgical approach initially proposed by Chinese scholar Liao Hua[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], drawing on the characteristics of endoscopy and referencing surgical modalities used in gynecological balloon pump procedures and urological bladder surgeries. This method has been further refined and popularized by Hou Zhaohui and Yu Youjun[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], addressing specific issues and shortcomings associated with traditional endoscopic ear surgery. CIM-EES has been designed to enhance clarity and smoothness in the endoscopic ear surgery process, thereby improving surgical outcomes and patient safety.\u003c/p\u003e \u003cp\u003eThis study delves into the application of the self-developed continuous irrigation mode in endoscopic surgery for EACC, highlighting the significance of CIM-EES in advancing the field of otological surgery.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eA. Research Subjects\u003c/h2\u003e \u003cp\u003eA retrospective analysis included 66 EACC patients (January 2022 \u0026ndash; December 2023) undergoing general anesthesia at Shenzhen Nanshan People\u0026rsquo;s Hospital. Patients were divided into two groups of 33 each: continuous irrigation mode (experimental) and non-irrigation mode (control). Prior to surgery, all patients underwent comprehensive audiological assessments, endoscopic evaluations, and temporal bone CT scans, performed by the same senior attending physician.\u003c/p\u003e \u003cp\u003eThe study's inclusion criteria were as follows: ①Patients could not endure the treatment in the outpatient setting through ear endoscopic; ② The age range was between 6 and 70 years; ③ EACC was classified as stages I and II according to Shin's classification [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]; ④ The surgery was conducted entirely under endoscopic visualization.\u0026rdquo; - \u0026ldquo;Exclusion criteria included: ① Patients with central nervous system disorders; ② Patients with coagulopathy; ③Patients with immune system disorders; ④ Patients with abnormal liver or kidney function; ⑤ Patients with malignant tumors; ⑥ Patients with psychiatric disorders; ⑦ Patients who were intolerant of surgery or had contraindications for surgical intervention. The study adhered to the ethical standards of the Helsinki Declaration, and all participants provided written informed consent prior to undergoing any procedures or operations(Ethical approval number:LW-2024-035).\u003c/p\u003e \u003cp\u003e \u003cem\u003eB. Production and Use of Continuous Irrigation Mode\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003e1) Materials\u003c/strong\u003e \u003cp\u003eThe assembly requires one disposable infusion set, two infusion extension tubes, one disposable long needle with a diameter of 1.2mm, one disposable suction catheter with a diameter of 4mm, and 3000ml bags of physiological sodium chloride solution at a concentration of 0.9% (27g/bag).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003e2)Assembly Method\u003c/strong\u003e \u003cp\u003eAs depicted in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003eA, the disposable infusion set(4\u0026rarr;) and the two infusion extension tubes(2/3\u0026rarr;) are connected in tandem. The sharp end of the infusion set is introduced into the physiological sodium chloride solution༈6\u0026rarr;༉from Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003eC, while one end of an infusion extension tube is attached to the disposable needle༈1\u0026rarr;༉. The connections should be secured with medical-grade adhesive to prevent fluid leakage. As illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003eB, a segment of the suction catheter༈5\u0026rarr;༉, approximately 3\u0026ndash;4 cm in length, is positioned at the front end of a 0\u0026deg; endoscope (diameter 3mm, Karl Storz, Germany). The disposable needle from Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003eA is then inserted through the gap between the suction catheter and the endoscope. The infusion set tube is subsequently attached to a power control system (Medtronic, USA) as illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003eC, with the irrigation mode being activated and deactivated using a foot pedal for precise control.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eC. Surgical Steps\u003c/h3\u003e\n\u003cp\u003eAll procedures were performed by the same seasoned chief surgeon, with comprehensive video documentation of each surgical step. Patients were administered general anesthesia. After completion of disinfection and draping, the irrigation device was connected, and a 3000ml bag of 0.9% physiological sodium chloride solution (27g/bag) was prepared. The irrigation control foot pedal was positioned at the assistant's footrest. The surgeon held the endoscope with the left hand and manipulated the surgical instruments with the right. The assistant also ensured the suction device was placed adjacent to the saline collection bag, external to the auricle, and adjusted it as necessary to maintain unobstructed operation. In the experimental group, the irrigation mode was initiated upon endoscope introduction, marking the commencement of surgery. Both groups proceeded with surgery according to standard protocols, with the surgeon adjusting the depth of the endoscope in response to the surgical field exposure. Upon completion of the surgery, the ear canal was treated with antibiotic ointment and hemostatic sponges.\u003c/p\u003e\n\u003ch3\u003eD.Outcome Metrics\u003c/h3\u003e\n\u003cp\u003eAll patients had their surgical procedures documented with video recordings. They were discharged the day following surgery and were prescribed a 5-day course of oral antibiotics. Ear endoscopies were scheduled on the 14th, 21st, and 28th postoperative days, as well as at 3 and 6 months post-surgery to assess the status of the external auditory canal flap and the tympanic membrane. Pure tone audiometry was conducted 6 months after the surgery.\u003c/p\u003e \u003cp\u003eKey metrics included intraoperative lens cleaning frequency, operation duration, postoperative complications, epithelialization time(defined as the external auditory canal having no exudate and the granulation tissue on its surface being covered by normal skin tissue), hearing improvement,cleaning frequency within 6 months, and recurrence rate of external auditory canal cholesteatoma .\u003c/p\u003e\n\u003ch3\u003eE. Statistical Methods\u003c/h3\u003e\n\u003cp\u003eData were analyzed using SPSS v26. Quantitative data that were normally distributed are presented as means\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviations, and independent samples t-tests were employed for comparing group means. Categorical data were compared between groups using chi-square tests. A p-value of less than 0.05 was considered to indicate statistical significance.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eA. General results\u003c/h2\u003e \u003cp\u003eOut of a total of 66 patients, all presented with unilateral cases. The experimental group comprised 15 males and 18 females with a mean age of (21.45\u0026thinsp;\u0026plusmn;\u0026thinsp;3.70) years, while the control group included 21 males and 12 females with a mean age of (23.52\u0026thinsp;\u0026plusmn;\u0026thinsp;3.89) years. In the control group, 12.1% (4/33) of the patients experienced varying degrees of intraoperative complications. Postoperatively, there have been no instances of recurrence of external auditory canal cholesteatoma or secondary middle ear cholesteatoma at over 1 year of follow-up. Two patients in the experimental group and four in the control group developed fungal external otitis, which subsequently resolved with conservative management.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eB. Significant Reduction in Complication Incidence in the Experimental Group\u003c/h3\u003e\n\u003cp\u003eAmong the 66 patients enrolled in the study, none experienced severe complications such as facial paralysis, hypogeusia, or vertigo. However, within the control group, two patients sustained intraoperative tears of the tympanic membrane. These tears were managed with the application of antibiotic gelatin sponge and resolved spontaneously within two weeks postoperatively. Additionally, one patient in the control group had exposure of bare bone in the ear canal, and another developed mild stenosis of the ear canal. In contrast, the experimental group demonstrated a significantly lower rate of complications with 0%. The statistical analysis revealed p\u0026lt;0.05, denoting a statistically significant difference in complication rates between the two groups.\u003c/p\u003e \u003cp\u003e \u003cem\u003eC. The intraoperative lens cleaning frequency and operation duration were significantly shortened in the experimental group\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThrough the analysis of the surgical video, the frequency of lens cleaning and operation duration of the two groups were counted, and the number of lens cleaning and operation duration of the experimental group were significantly shortened, ρ\u0026thinsp;\u0026lt;\u0026thinsp;0.05. The difference was statistically significant, as shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eThe intraoperative lens cleaning frequency and operation duration were compared in the experimental group\u003c/span\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLens cleaning frequency\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOperation duration (minutes)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eexperimental group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.24\u0026thinsp;\u0026plusmn;\u0026thinsp;0.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.93\u0026thinsp;\u0026plusmn;\u0026thinsp;1.20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003econtrol group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26.67\u0026thinsp;\u0026plusmn;\u0026thinsp;4.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24.65\u0026thinsp;\u0026plusmn;\u0026thinsp;3.48\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003et\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20.18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:{\\rho\\:}\\)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003eD. Postoperative Ear Canal Epithelialization Time Was Reduced\u003c/h3\u003e\n\u003cp\u003eOn the 14th postoperative day, the external auditory canals of all patients were endoscopically inspected to remove any residual hemostatic sponges and to assess the condition of the surgical cavity and the tympanic membrane. At the initial postoperative review, the tympanic membranes of all 66 patients were found to be intact, while the external auditory canal epithelium exhibited varying degrees of erythema, edema, and serous discharge. Subsequent ear endoscopies were scheduled at 21, 28 days, and at 3 and 6 months postoperatively to document the status of the skin and tympanic membrane within the external auditory canal. Based on the condition of the external ear canal skin, the frequency of follow-up visits was adjusted, and the number of ear canal cleanings within the first 6 postoperative months was recorded. Comparative analysis of these data revealed that the experimental group had a shorter postoperative ear canal epithelialization time and a significantly reduced number of ear canal cleanings within 6 months compared to the control group. For detailed statistics, refer to Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eThe epithelialization time and frequency of ear canal cleaning were compared in the experimental group\u003c/span\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEar canal epithelialization time (days)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFrequency of ear canal cleaning (times)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eexperimental group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16.30\u0026thinsp;\u0026plusmn;\u0026thinsp;2.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.76\u0026thinsp;\u0026plusmn;\u0026thinsp;0.66\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003econtrol group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26.64\u0026thinsp;\u0026plusmn;\u0026thinsp;11.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.73\u0026thinsp;\u0026plusmn;\u0026thinsp;1.31\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003et\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25.68\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:{\\rho\\:}\\)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eE. No Significant Difference in Postoperative Hearing Improvement Between Groups\u003c/h2\u003e \u003cp\u003eThe average Air-Bone Gap (ABG) at frequencies of 0.5 kHz, 1 kHz, 2 kHz, and 4 kHz was calculated for each patient. In the experimental group, the preoperative ABG was (14.53\u0026thinsp;\u0026plusmn;\u0026thinsp;3.86) dB HL, which reduced to a postoperative ABG of (3.20\u0026thinsp;\u0026plusmn;\u0026thinsp;1.90) dB HL. For the control group, the preoperative ABG was (18.83\u0026thinsp;\u0026plusmn;\u0026thinsp;8.56) dB HL, and the postoperative ABG was (3.00\u0026thinsp;\u0026plusmn;\u0026thinsp;1.96) dB HL. Statistical comparison of the two groups' data revealed a p\u0026thinsp;\u0026gt;\u0026thinsp;0.05, indicating no significant difference in postoperative hearing improvement between the experimental and control groups.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eA.Advantages of CIM-EES for EACC\u003c/h2\u003e \u003cp\u003eThe advent of Continuous Irrigating Mode for Endoscopic Ear Surgery (CIM-EES) has been timely in addressing the challenges associated with EACC. Patients with this condition often present with substantial keratin debris obstructing the ear canal, along with granulation tissue hyperplasia and bone destruction [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Traditional endoscopic surgery can pose risks to the external auditory canal flap, the mastoid segment of the facial nerve, or the tympanic membrane due to bleeding from granulation tissue, potentially leading to postoperative complications such as ear canal scarring, facial nerve injury, or tympanic membrane perforation [\u003cspan additionalcitationids=\"CR12 CR13 CR14 CR15\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCIM-EES facilitates the formation of a water flow within the intraoperative cavity under controlled pressure for outward one-way circulation. Blood seepage and bone residue, which are common during surgery, are flushed out of the ear canal by this pressured water flow. This process helps maintain a clear endoscopic field of view and intraoperative cavity, enhancing the convenience and fluency of the surgical procedure, and increasing surgical safety [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Currently, CIM-EES has been applied in endoscopic tympanic membrane repair, tympanoplasty, middle ear cholesteatoma surgery, facial nerve decompression, and transmeatal-promontory acoustic neuroma resection, among others [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe purpose of this study was to investigate the application of CIM-EES in EES for EACC. The results showed that the frequency of intraoperative lens cleaning (3.24\u0026thinsp;\u0026plusmn;\u0026thinsp;0.71 times), operation duration (10.93\u0026thinsp;\u0026plusmn;\u0026thinsp;1.20 minutes), the incidence of complication (0), epithelialization time of external ear canal (16.30\u0026thinsp;\u0026plusmn;\u0026thinsp;2.27 days) ,and postoperative cleaning times(1.76\u0026thinsp;\u0026plusmn;\u0026thinsp;0.66 times) in experimental group were significantly lower than those in control group. Continuous irrigating mode effectively reduces intraoperative lens contamination and surgical interruption by removing bleeding and cholestatoma epithelium in real time, significantly improving surgical fluency and efficiency. This technical advantage is particularly important for patients with cholestatoma of the external auditory canal, as a clear field of view is essential for complete removal of cholestatoma and avoidance of residual cholestatoma (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e2\u003c/span\u003e). In addition, the clear surgical field directly separated the lesion from the ear canal epithelium, tympanic membrane, and facial nerve, reducing the possibility of intraoperative damage to important structures and improving the accuracy of the operator's operation. This improvement is especially suitable for the removal of cholesteatoma of the external ear meatus which requires very high surgical field. During the operation, the high-flow lavage liquid directly cleared the cholestatoma epithelium attached to the skin surface of the external ear canal and the surface of the eardrum, reducing the stimulation of the ear canal skin and the eardrum, reducing the risk of eardrum tearing and the risk of postoperative ear canal skin swelling and scar stenosis. The skin of the external auditory canal is well protected and can quickly restore epithelialization, and greatly facilitating the recovery and follow-up management of patients.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eB. Structural advantages of self-developed irrigation mode\u003c/h2\u003e \u003cp\u003eThe widely used irrigation devices in the domestic market are associated with higher costs, which may limit their accessibility and application in some settings.Another drawback of the existing irrigation devices is their limited compatibility with different brands of endoscopes. This lack of versatility can pose challenges in clinical practice, as hospitals often use endoscopes from various manufacturers. By highlighting these differences and advantages, we aim to provide a stronger context for the superiority of our CIM-EES approach.\u003c/p\u003e \u003cp\u003eThe novel continuous irrigation mode, as utilized in this study, offers structural advantages that address the high costs associated with commercially available irrigation devices and equipment. This device has been previously applied by domestic scholars in endoscopic tympanic cholesteatoma surgery, demonstrating its practicality [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Constructed from basic medical disposables, the device is characterized by its low cost and ease of assembly. The design emphasizes continuous perfusion and endoscope lens cleaning through a secure connection between the disposable needle and the endoscope's front end, ensuring a clear surgical field and preventing fluid residue accumulation in front of the lens sheath and body. By integrating the perfusion line into the Medtronic power system, we have omitted the need for a pressure pump, allowing for foot-controlled perfusion mode activation and deactivation. This self-made device caters to the needs of primary hospitals and resource-limited settings, providing a cost-effective solution for ear surgery.\u003c/p\u003e \u003cp\u003eThe pressurization system of our self-made device leverages the control valve from a standard power system, maintaining a stable perfusion speed while avoiding the high costs associated with complex pump systems. In this study, a flow rate of 0.2 L/min was found to be effective for clearing blood and debris from the surgical field, eliminating the need for a high-precision pressure controller. This innovative design holds significant value for primary healthcare institutions.\u003c/p\u003e \u003cp\u003eDespite the CIM-EES model's clear benefits in enhancing surgical efficiency and safety, several challenges accompany its implementation. Surgeons must adjust to the perfusion velocity and pressure to prevent damage to the ear canal flap and tympanic membrane from the force of the perfusion fluid. Our self-made devices, assembled from various simple consumables, currently lack a uniform standard, which may lead to variability in their performance across different medical institutions. Additionally, the performance and stability of these devices in long-term or high-frequency surgical procedures require further validation. The manufacturing and installation of perfusion devices also necessitate a certain level of proficiency, potentially hindering their adoption in primary hospitals. Future improvements in device design and standardized operating procedures could enhance the technology's ease of use and adaptability.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eC. Limitations and Future Directions of This Study\u003c/h2\u003e \u003cp\u003eThis study represents a retrospective analysis with a limited number of cases and a short postoperative follow-up period, which restricts the comprehensive assessment of long-term outcomes. Future multi-center, large-sample prospective studies will be instrumental in further validating the applicability of the CIM-EES model across a range of ear diseases. Moreover, integrating intelligent equipment to optimize the perfusion mode, including precise pressure control and real-time field of view analysis, may lead to further enhancements in the operating experience and clinical outcomes of endoscopic ear surgery.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe present study demonstrates that the utilization of a novel continuous irrigation mode in endoscopic surgery for external auditory meatus cholesteatoma yields significant benefits. It not only substantially reduced the operative duration and the frequency of intraoperative lens cleaning and visual obscuration but also lowered the incidence of postoperative complications and recurrence rates. This approach is characterized by its ease of operation, safety, and efficacy, making it a viable candidate for widespread adoption, particularly in primary healthcare settings. Looking ahead, the integration of intelligent equipment to refine perfusion modalities has the potential to enhance surgical efficiency and patient outcomes, offering innovative insights into the advancement of ear endoscopic surgical techniques.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eABG\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eair-bone gap\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eEACC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eexternal auditory canal cholesteatoma\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eEES\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eendoscopic ear surgery\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCIM-EES\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003econtinuous irrigating mode for endoscopic ear surgery\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eSource of financial support in the form of grants:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by grants from the Nanshan District Medical Key Discipline Construction Financial Support Project.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNan Zeng was responsible for designing the theme. Qiong Yang, Lue Zhang and Jing Hu were responsible for data collection and surgical procedures.Mingxing Tang and Shuo Li were responsible for data statistics and analysis. Because this research is designed and carried out under the guidance of Shang Yan, he is the correspondence author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest Statement\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no conflicts of interest.\u003c/p\u003e\n\u003cp\u003eEthics approval and consent to participate：Ethics Committee approval was obtained.\u003c/p\u003e\n\u003cp\u003eConsent for publication: Written informed consent for publication of their clinical details and clinical mages was obtained from the patient.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials: The datasets used and analysed during the current study are available from the corresponding author on reasonable request via the email [email protected].\u003c/p\u003e\n\u003cp\u003eCompeting interests: The authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003eAcknowledgements: Thank every author for his work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of Figures Authenticity:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll figures submitted have been created by the authors who confirm that the images are original with no duplication and have not been previously published in whole or in part.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eQian, M. F. et al. Clinical characteristics and treatment of external auditory canal cholesteatoma. \u003cem\u003eJ. Audiol. Speech Pathol.\u003c/em\u003e \u003cb\u003e24\u003c/b\u003e (02), 149\u0026ndash;152 (2016, March).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHUANG J., LI Y., PENG T., FENG B. May). Current Status of Diagnosis and Treatment of External Auditory Canal Cholesteatoma. \u003cem\u003eChin. J. Otorhinolaryngol.\u003c/em\u003e, \u003cb\u003e18\u003c/b\u003e(05), 957\u0026ndash;961. (2020).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMarchioni, D. et al. Complications in Endoscopic Ear Surgery. \u003cem\u003eOtol Neurotol\u003c/em\u003e. \u003cb\u003e39\u003c/b\u003e (8), 1012\u0026ndash;1017 (2018).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStern Shavit, S., Sharma, R. K., Chern, A. \u0026amp; Golub, J. S. Pearls and Pitfalls in Endoscopic Ear Surgery. \u003cem\u003eOtolaryngol. Clin. North. Am.\u003c/em\u003e \u003cb\u003e54\u003c/b\u003e (1), 201\u0026ndash;209 (2021, February).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKozin, E. D. et al. Thermal effects of endoscopy in a human temporal bone model: implications for endoscopic ear surgery. \u003cem\u003eLaryngoscope\u003c/em\u003e \u003cb\u003e124\u003c/b\u003e (8), E332\u0026ndash;E339 (2014, August).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMitchell, S. \u0026amp; Coulson, C. Endoscopic ear surgery: a hot topic? \u003cem\u003eJ. Laryngol Otol\u003c/em\u003e. \u003cb\u003e131\u003c/b\u003e (2), 117\u0026ndash;122 (2017, February).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiao, H. et al. June). A novel continuous irrigating endoscopic ear surgery mode for Type I tynpanoplasty. \u003cem\u003eJ. Audiol. Speech Pathol.\u003c/em\u003e \u003cb\u003e27\u003c/b\u003e (6), 615\u0026ndash;618 (2019).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLIAO H., YU Y., HOU Z. Continuous Irrigation in Endoscopic Ear Surgery. \u003cem\u003eChin. J. Otology\u003c/em\u003e, \u003cb\u003e19\u003c/b\u003e(2), 192\u0026ndash;197. (2021), February.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShin, S. H., Shim, J. H. \u0026amp; Lee, H. K. Classification of external auditory canal cholesteatoma by computed tomography. \u003cem\u003eClin. Exp. Otorhinolaryngol.\u003c/em\u003e \u003cb\u003e3\u003c/b\u003e (1), 24\u0026ndash;26 (2010, March).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBonding, P. \u0026amp; Ravn, T. Primary cholesteatoma of the external auditory canal: is the epithelial migration defective? \u003cem\u003eOtol Neurotol\u003c/em\u003e. \u003cb\u003e29\u003c/b\u003e (3), 334\u0026ndash;338 (2008).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNogueira, J. F., de Querido, S. L. F., Gon\u0026ccedil;alves da Silva Leite, R. \u0026amp; da Costa, J. T. Future of Endoscopic Ear Surgery. \u003cem\u003eOtolaryngol Clin North Am\u003c/em\u003e., 54(1), 221\u0026ndash;231. (2021), February.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNaim, R., Sadick, H., Schafer, C. \u0026amp; Hormann, K. External auditory canal cholesteatoma: analysis of the integrity of the tissue structure. \u003cem\u003eInt. J. Mol. Med.\u003c/em\u003e \u003cb\u003e14\u003c/b\u003e (4), 601\u0026ndash;604 (2004, April).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang, Y. et al. December). External auditory canal cholesteatoma in children: clinical manifestations. \u003cem\u003eEur. Arch. Otorhinolaryngol.\u003c/em\u003e \u003cb\u003e281\u003c/b\u003e (12), 6645\u0026ndash;6651 (2024).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHeilbrun, M. E. et al. External auditory canal cholesteatoma: clinical and imaging spectrum. \u003cem\u003eAJNR Am. J. Neuroradiol.\u003c/em\u003e \u003cb\u003e24\u003c/b\u003e (4), 751\u0026ndash;756 (2003, April).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang, X. L. \u0026amp; Jin, L. Clinical Analysis of 36 Cases with External Auditory Canal Cholesteatoma. \u003cem\u003eSurg. Res. New. Techniques\u003c/em\u003e. \u003cb\u003e10\u003c/b\u003e (04), 273\u0026ndash;276 (2021, April).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhou, N., Li, L. B. \u0026amp; Lin, L. Clinical Characteristics and Surgical Treatment of Types II-IV External Auditory Canal Cholesteatoma. \u003cem\u003eJ. Clin. Otolaryngol. Head Neck Surg.\u003c/em\u003e \u003cb\u003e30\u003c/b\u003e (16), 1287\u0026ndash;1289 (2016, August).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiao, H. et al. Expert Consensus on Continuous Irrigation Mode in Endoscopic Otologic Surgery. \u003cem\u003eJ. Clin. Otolaryngol. Head Neck Surg.\u003c/em\u003e \u003cb\u003e38\u003c/b\u003e (02), 93\u0026ndash;97 (2024, February).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi, Y. et al. November). Application of Self-made Continuous Irrigation Device in Endoscopic Surgery for Supratympanic Cholesteatoma. \u003cem\u003eChin. J. Otorhinolaryngol. Head Neck Surg.\u003c/em\u003e \u003cb\u003e57\u003c/b\u003e (11), 1319\u0026ndash;1322 (2022).\u003c/span\u003e\u003c/li\u003e \u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Continuous Irrigating Mode, Endoscopic Ear Surgery, External Auditory Canal Cholesteatoma","lastPublishedDoi":"10.21203/rs.3.rs-5766579/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5766579/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eTo evaluate the application and efficacy of a novel continuous irrigation mode in endoscopic ear surgery for external auditory canal cholesteatoma (EACC).\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA retrospective analysis of 66 patients undergoing surgery for EACC at Shenzhen Nanshan People\u0026rsquo;s Hospital (January 2022 \u0026ndash; December 2023) was conducted. Patients were divided into two groups of 33 each: continuous irrigation mode (experimental) and non-irrigation mode (control). Key metrics included intraoperative lens cleaning frequency, operation duration, postoperative complications, epithelialization time(defined as the external auditory canal having no exudate and the granulation tissue on its surface being covered by normal skin tissue), hearing improvement,cleaning frequency within 6 months, and recurrence rate of external auditory canal cholesteatoma .\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe experimental group demonstrated shorter operation time, fewer lens cleanings, reduced complication rates, faster epithelialization, and lower postoperative cleaning frequency (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Hearing improvement and recurrence rates were comparable between groups (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe novel continuous irrigation mode significantly enhances surgical efficiency, safety, and outcomes in EACC management, with potential for broad application in primary healthcare settings.\u003c/p\u003e","manuscriptTitle":"Efficacy of a Novel Continuous Irrigation Mode in Endoscopic Ear Surgery for External Auditory Canal Cholesteatoma","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-01-15 11:44:52","doi":"10.21203/rs.3.rs-5766579/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e8ce94fb-1dbc-4419-9f9e-146e90322f8c","owner":[],"postedDate":"January 15th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":42745166,"name":"Biological sciences/Biological techniques"},{"id":42745167,"name":"Health sciences/Diseases"},{"id":42745168,"name":"Health sciences/Health care"},{"id":42745169,"name":"Health sciences/Medical research"}],"tags":[],"updatedAt":"2025-02-03T08:09:05+00:00","versionOfRecord":[],"versionCreatedAt":"2025-01-15 11:44:52","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5766579","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5766579","identity":"rs-5766579","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}