The Journal of International
Advanced Otology
Original Article

Time Flow Study to Assess Opportunities to Improve Efficiency in Endoscopic Tympanoplasty


Department of Otolaryngology-Head and Neck Surgery, Hospital for Sick Children, University of Toronto, Canada


Centre for Image-Guided Innovation and Therapeutic Intervention (CIGITI), The Hospital for Sick Children, Toronto, Canada


Institute of Biomedical Engineering, University of Toronto, Toronto, Canada


Khon Kaen Ear, Hearing and Balance Research Group, Department of Otorhinolaryngology, Khon Kaen University, Khon Kaen, Thailand


Department of Otorhinolaryngology, Faculty of Medicine, Khon Kaen University, Thailand


Faculty of Medicine, University of Toronto, Toronto, Canada

J Int Adv Otol 2021; 17: 288-293
DOI: 10.5152/iao.2021.9232
Read: 1658 Downloads: 537 Published: 01 July 2021

BACKGROUND: To characterize the workflow during transcanal totally endoscopic tympanoplasty by recording the time and instrumentation used for different steps in the procedure. This analysis aims to identify aspects of instrumentation and surgical technique that could be modified to improve surgical efficiency.

METHODS: Thirty-one endoscopic tympanoplasty procedures were observed at a single academic center. Patient age ranged from 2.7 to 17.8 years. The procedure was separated into distinct steps. The duration in minutes and the instruments used were recorded by an independent observer.

RESULTS: Raising the tympanomeatal flap (median 9.82 minutes) and positioning the graft and replacing the flap (median 9.13 minutes) took significantly longer than all other steps (P < .05, Wilcoxon method). Teaching a trainee significantly increased step duration by a total of 32.8 minutes (P < .05, Wilcoxon method). There was no correlation between age of the patient, side of the ear, surgical technique, or graft type, and duration of surgery. Suction instruments with a functional tip (dissector or knife tip) were most commonly used to dissect and maneuver soft tissue while maintaining the surgical field clear of blood.

CONCLUSION: As elevation of the tympanomeatal flap and graft placement are the most time-consuming steps in endoscopic tympanoplasty, especially for surgical trainees, surgical efficiency could most dramatically be enhanced by modification of instrumentation or technique to facilitate these steps. Modification of simpler steps such as hair trimming and ear canal packing have less potential for shortening surgical duration.

Cite this article as: Swarup A, Chayaopas N, W. Eastwood K, James A. Time flow study to assess opportunities to improve efficiency in endoscopic tympanoplasty. J Int Adv Otol. 2021; 17(4): 288-293.

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