An exclusive transcanal endoscopic approach was performed under general anesthesia on September 2022. A 0°, 3 mm ø, 14 cm length endoscope (Karl Storz SE & Co. KG, Tuttlingen, Germany) was used. The procedure began with local infiltration of the ear canal (Ultracain® Laboratorios Normon S.A., Madrid, Spain). Neurosurgical patties soaked in lidocaine (B. Braun 20 mg/ml, 10 ml) with epinephrine (B. Braun 1 mg/ml, 0.5 ml) were helpful in controlling intraoperative bleeding as well as lavages.

The surgical phases were: (1) Tumour exposure: The technique involved the elevation of an extense, anterosuperior based, tympanomeatal flap; (2) Tumour reduction: coagulation of the tumour surface by blue laser fibre (2 W, 0.08 s/pulse; 2.5W 0.12 s/pulse – Fibre 300 μ, Blue laser WOLF TruBlue, Neomed, UK) and otology handpiece; (3) Tumour dissection and excision from posterior to anterior, searching when possible the main vascular supply. The suction dissector (Karl Storz SE & Co. KG, Tuttlingen, Germany) was very useful at this stage of the surgery. Traction dissection helped in the final stage of the tumour extraction; (4) Haemostasis and vaporisation of tumour bed residues by a blue laser. In the last two phases of the procedure, three-handed work was performed (two surgeons). The procedure ended with the reinforcement of the tympanic membrane with temporalis muscle fascia placed in an underlay fashion and the replacement of the tympanomeatal flap. The packaging consisted of an absorbable gelatine sponge filling the external auditory canal and a silicone sheet (See video, Supplemental Digital Content 1, illustrating technique). Surgery time was 90 min.

The patient was discharged, without incident, on the same day. Histopathology confirmed the diagnosis. At one-year follow-up, the tinnitus disappeared although a mild sensorineural hearing loss was observed (Fig. 2a, b). Otherwise, no recurrence was observed.

Preoperative (a) and 12-months postoperative (b) pure tone audiograms