Devices, systems, and methods for otology

Abstract

Devices, systems, and methods for facilitating performing procedures in the outer, middle, and inner ear may be used to diagnose and / or treat disorders, including, but not limited to, hearing loss and other ear disorders. For example, this document describes devices, systems, and methods, including instruments and techniques, that minimize the invasiveness and / or enhance the effectiveness of procedures performed in the outer, middle, and / or inner ear spaces, such as mastoidectomy, tympanoplasty, cholesteatoma treatment, otosclerosis treatment, and Eustachian tube treatment.

Description

[Technical Field]

[0001] CROSS-REFERENCE TO RELATED APPLICATIONS This application is a continuation of U.S. Provisional Application No. 62 / 965,481, filed January 24, 2020, U.S. Provisional Application No. 63 / 024,183, filed May 13, 2020 (which are incorporated by reference in their entirety), U.S. Provisional Application No. 63 / 040,495, filed June 17, 2020 (which are incorporated by reference in their entirety), U.S. Provisional Application No. 63 / 051,568, filed July 14, 2020 (which are incorporated by reference in their entirety), U.S. Provisional Application No. 63 / 077,448, filed September 11, 2020 (which are incorporated by reference in their entirety). This application claims the benefit of priority to U.S. Provisional Application No. 63 / 078,141, filed September 14, 2020 (which is incorporated by reference herein in its entirety), U.S. Provisional Application No. 63 / 080,510, filed September 18, 2020 (which is incorporated by reference herein in its entirety), U.S. Provisional Application No. 63 / 081,015, filed September 21, 2020 (which is incorporated by reference herein in its entirety), and U.S. Provisional Application No. 63 / 082,996, filed September 24, 2020 (which is incorporated by reference herein in its entirety).

[0002] This document relates to devices, systems, and methods for facilitating procedures in the outer, middle, and inner ear to diagnose and / or treat disorders, including, but not limited to, hearing loss and other ear disorders. In some examples, the systems and methods include instruments and techniques that can be used to minimize the invasiveness of procedures performed in the outer, middle, and / or inner ear spaces. [Background technology]

[0003] The human ear is subject to a variety of disorders including, but not limited to, hearing loss, tinnitus, balance disorders including vertigo, Meniere's disease, vestibular neuritis, vestibular schwannoma, labyrinthitis, otosclerosis, ossicular chain luxation, cholesteatoma, outer ear infections, middle ear infections, and tympanic membrane perforation, to provide a few examples.

[0004] In one example, conductive hearing loss (CHL) involves the loss of the normal mechanical pathway for sound to reach the hair cells in the cochlea due to, for example, malformations, fluid accumulation in the middle ear, destruction of the eardrum, the presence of a tumor, and / or damage to the ossicles. Sensorineural hearing loss (SNHL) results from the absence or damage of hair cells in the cochlea or impaired downstream neural signaling. SNHL is typically associated with exposure to loud noise, head trauma, aging, infections, Meniere's disease, tumors, ototoxicity, genetic disorders such as Usher syndrome, and the like. Summary of the Invention [Problem to be solved by the invention]

[0005] This document describes devices, systems, and methods for applications such as, but not limited to, performing procedures in the outer ear, middle ear, and inner ear to diagnose and / or treat disorders, including, but not limited to, hearing loss and other ear disorders. For example, this document describes devices, systems, and methods, including instruments and techniques, for minimizing the invasiveness and / or enhancing the effectiveness of procedures performed in the outer ear, middle ear, and / or inner ear spaces. [Means for solving the problem]

[0006] In some embodiments, the devices, systems, and methods for facilitating procedures described herein can be used for middle and / or inner ear procedures involving surgical access via approaches including (but not limited to) transmastoid, transcanal, intraaural, retroaural, postaural, and others. For example, techniques and instruments for performing transmastoid access to the middle ear cavity with reduced levels of invasiveness are described herein. In another example, the present disclosure describes instruments and techniques for minimally invasive debulking of cholesteatoma. In addition, enhanced instruments and techniques for procedures such as tympanoplasty and myringotomy are described herein. Furthermore, the devices, systems, and methods described herein are well suited for use in other cavities or spaces within the body and other approaches in addition to visualizing the middle and / or inner ear. For example, the devices, systems, and methods are well suited for visualization and treatment of the Eustachian tube, mastoid sinus space, and epitympanic cavity, among others.

[0007] The devices, systems, and methods described herein may be used in conjunction with additional treatment techniques, for example, the devices, systems, and methods described herein may be used in conjunction with treatment techniques such as, but not limited to, therapeutic agent delivery (which may be in the form of a gel, liquid, or solid), antibiotic delivery, gene delivery, device or implant delivery, diagnostic procedures, and surgical procedures, among others.

[0008] In one aspect, the present disclosure is directed to a method for treating a cholesteatoma or soft tissue lesion in the middle ear. The method includes advancing a shaft of an instrument through the ear canal so that a distal tip of the instrument contacts the cholesteatoma or soft tissue lesion in the middle ear. The method also includes delivering a therapeutic treatment from the instrument to the cholesteatoma or soft tissue lesion to debulk the cholesteatoma or soft tissue lesion.

[0009] Such methods for treating a cholesteatoma or soft tissue lesion in the middle ear may optionally include one or more of the following features: The advancing step may include passing the shaft of an instrument through a perforation in a tympanic membrane located between the ear canal and the middle ear. The method may also include placing a port device within the perforation. The advancing step may include passing the shaft of an instrument through a lumen of the port device while the port device is within the perforation. The instrument may be an injection instrument. The delivering a therapeutic treatment agent may include injecting an agent from the injection instrument into the cholesteatoma or soft tissue lesion. The instrument may be an ultrasonic instrument. The delivering a therapeutic treatment agent may include applying ultrasonic energy from the ultrasonic instrument to the cholesteatoma or soft tissue lesion to emulsify at least a portion of the cholesteatoma or soft tissue lesion. The instrument may be a laser instrument. The delivering a therapeutic treatment agent may include applying laser energy to the cholesteatoma or soft tissue lesion.

[0010] In another aspect, the present disclosure is directed to a method for removing ossification buildup around the stapes footplate in the middle ear. The method includes advancing an instrument shaft through the ear canal so that a distal tip of the instrument is in proximity to the ossification buildup around the stapes footplate. The method further includes delivering a therapeutic treatment from the instrument to the ossification buildup around the stapes footplate to remove at least a portion of the buildup. Such methods for removing ossification buildup around the stapes footplate in the middle ear may optionally include one or more of the following features: The advancing step may include passing the instrument shaft through a perforation in the tympanic membrane located between the ear canal and the middle ear. The method may also include placing a port device within the perforation. The advancing step may include passing the instrument shaft through a lumen of the port device while the port device is within the perforation. The instrument may be a cutting and suction instrument. The step of delivering the therapeutic treatment agent may include cutting and aspirating a portion of the buildup using a cutting and aspirating instrument. The instrument may be an ultrasonic instrument. The step of delivering the therapeutic treatment agent may include applying ultrasonic energy from the ultrasonic instrument to the buildup to emulsify at least a portion of the buildup. The instrument may be a laser instrument. The step of delivering the therapeutic treatment agent may include applying laser energy from the laser instrument to the buildup to remove at least a portion of the buildup. The instrument may be a diathermy instrument. The step of delivering the therapeutic treatment agent may include applying thermal energy from the diathermy instrument to the buildup to remove at least a portion of the buildup.

[0011] In another aspect, the present disclosure is directed to a method for treating otosclerosis in the middle ear. The method includes advancing a shaft of an instrument through the ear canal so that a distal tip of the instrument is within the middle ear. The method also includes delivering a therapeutic treatment from the instrument. The instrument can be (i) a cutting and suction instrument, (ii) an ultrasonic instrument, (iii) a laser instrument, or (iv) a diathermy instrument.

[0012] In another aspect, the present disclosure is directed to a method for resurfacing around a perforation in a tympanic membrane, the method including advancing a shaft of a reciprocating cutting instrument through the ear canal toward the perforation, and actuating the reciprocating cutting instrument to remove tissue from around the perforation in the tympanic membrane.

[0013] Such methods for resurfacing the area surrounding the tympanic membrane perforation may also include aspirating at least a portion of the tissue removed from the area surrounding the tympanic membrane perforation with a reciprocating cutting instrument.

[0014] In another aspect, the present disclosure is directed to another method for resurfacing around a perforation in a tympanic membrane. The method includes advancing a shaft of an ultrasonic instrument through the ear canal toward the perforation. The method also includes activating the ultrasonic instrument to remove tissue from around the perforation in the tympanic membrane.

[0015] In another aspect, the present disclosure is directed to a method for treating Eustachian tube dysfunction, the method including the steps of (i) advancing a shaft of an instrument through the ear canal toward the Eustachian tube, the instrument including a balloon at a distal end of the shaft, the balloon being in a deflated state during advancement, (ii) positioning the balloon within the Eustachian canal, and (iii) inflating the balloon while it is in the Eustachian canal.

[0016] Such methods for treating Eustachian tube dysfunction may optionally include one or more of the following features: The advancing step may include passing an instrument shaft through a perforation in the tympanic membrane located between the ear canal and the Eustachian tube. The method may also include placing a port device within the perforation. The advancing step may include passing an instrument shaft through a lumen of the port device while the port device is within the perforation. The advancing step may include passing the instrument shaft through an opening of a tympanostomy ear drainage tube located within the tympanic membrane. In some embodiments, a stent device is placed over the balloon during advancement. In some such embodiments, inflating the balloon while it is within the Eustachian tube expands the stent device such that the expanded stent device holds the Eustachian tube open after removing the balloon from the Eustachian tube. The stent device may be a drug-eluting stent device.

[0017] In another aspect, the present disclosure is directed to another method for treating a cholesteatoma or soft tissue lesion in the middle ear. The method includes advancing a shaft of an instrument through a transmastoid access opening so that a distal tip of the instrument contacts the cholesteatoma or soft tissue lesion in the middle ear. The method also includes delivering a therapeutic treatment from the instrument to the cholesteatoma or soft tissue lesion to debulk the cholesteatoma or soft tissue lesion.

[0018] Such methods for treating a cholesteatoma or soft tissue lesion in the middle ear may optionally include one or more of the following features: The instrument may be an injection instrument. Delivering the therapeutic treatment agent may include injecting an agent from the injection instrument into the cholesteatoma or soft tissue lesion. The instrument may be an ultrasonic instrument. Delivering the therapeutic treatment agent may include applying ultrasonic energy from the ultrasonic instrument to the cholesteatoma or soft tissue lesion to emulsify at least a portion of the cholesteatoma or soft tissue lesion. The instrument may be a laser instrument. Delivering the therapeutic treatment agent may include applying laser energy to the cholesteatoma or soft tissue lesion.

[0019] Some or all of the embodiments described herein may provide one or more of the following advantages. First, some embodiments of the instruments and related techniques for treating or diagnosing ear disorders described herein reduce the invasiveness of the procedure compared to conventional methods. For example, instruments and techniques are disclosed for reducing the invasiveness of transmastoid access to the middle and / or inner ear. Thus, fewer mastoid removals (mastoidectomies) are required. Thus, recovery time, treatment costs, and potential complications are all potentially reduced. In another example, debulking of a cholesteatoma may be performed in a minimally invasive manner using the instruments and techniques described herein.

[0020] Second, the use of the instruments and techniques described herein can enhance the effectiveness of various ear procedures. For example, improved tools and methods for debulking cholesteatoma in a minimally invasive manner are described herein. Such tools include, but are not limited to, ultrasonic instruments, high-speed cutting instruments, injection instruments, diathermy instruments, and laser instruments, to provide a few examples. In another example, procedures for addressing otosclerosis can be performed with increased effectiveness using the instruments and techniques described herein. This is because, for example, the instruments and techniques described herein can be precisely used to remove buildup while preserving the stapes. In another example, instruments and techniques are described for reducing procedure time and risk of complications in standard stapedectomies and stapes surgeries. In yet another example, improved instruments and techniques for tympanoplasty can be performed with increased effectiveness.

[0021] Third, new types of otologic instruments are described herein, such as instruments for microdiathermy, pneumatic or electrically driven cutters, suction cutters, micro-suction, ultrasonic cutter / debriders, etc., and combinations thereof. The specialized instruments and techniques described herein facilitate the performance of new types of therapeutic procedures for disorders of the inner and middle ear. In addition, the therapeutic procedures may be performed with increased effectiveness and efficiency using the specialized instruments and techniques described herein.

[0022] Fourth, the devices, systems, and methods described herein advantageously allow for the ability to pass instruments through the surgical field and function in fluid-filled spaces in addition to air-filled spaces.

[0023] Fifth, methods are described herein for temporarily filling the middle and / or outer ear cavities so that therapeutic procedures can be performed "underwater." This approach, as described herein, offers several advantages, including, but not limited to, maintaining fluid balance within the cochlea during surgery, tamponading bleeding, enabling suction procedures that allow for continuous irrigation or flushing of middle ear structures, improving visualization, and enabling the precise use of suction cutters to trim or remove tissue during surgery.

[0024] Sixth, the systems described herein can also be used for diagnostic purposes. Such uses can aid in planning treatment, altering the location of care, and potentially improving patient outcomes.

[0025] The details of one or more embodiments of the invention are set forth in the accompanying drawings and the description below. Other features, objects, and advantages of the invention will be apparent from the description and drawings, and from the claims. [Brief explanation of the drawings]

[0026] [Figure 1] 1 is a schematic diagram of a conventional transmastoid access medical procedure. [Figure 2] 1 is a schematic diagram comparing the extent of mastoidectomy associated with a conventional transmastoid access medical procedure and a transmastoid access medical procedure using the instruments and techniques described herein. [Figure 3] 1A-1C are diagrams illustrating a schematic representation of a transmastoid access medical procedure using the described instruments and techniques. [Figure 4] 1A-1C illustrate an exemplary technique for debulking a cholesteatoma, according to some embodiments. [Figure 4A] FIG. 5 is a perspective view of a tympanic membrane port device that may be used for the technique shown in FIG. [Figure 4B] FIG. 4B illustrates the tympanic membrane port device of FIG. 4A positioned within the tympanic membrane. [Figure 5] FIG. 10 illustrates another technique for debulking a cholesteatoma, according to some embodiments. [Figure 6] 1A-1C illustrate an exemplary stapedectomy that may be performed with increased effectiveness using the instruments and techniques described herein. [Figure 7] 1A-1C illustrate an exemplary myringotomy procedure that may be performed with increased effectiveness using the instruments and techniques described herein. [Figure 8] 1A-1C illustrate an exemplary myringotomy procedure that may be performed with increased effectiveness using the instruments and techniques described herein. [Figure 9] 1A-1C illustrate another exemplary myringotomy procedure according to some embodiments. [Figure 10] 10A-10C illustrate another exemplary technique for performing an ear procedure in a fluid-filled space. [Figure 11] FIG. 1 illustrates an exemplary diathermy device, according to some embodiments. [Figure 12] 12A and 12B show an optional distal tip portion of the diathermy device of FIG. 11. [Figure 13] 1A-1C illustrate an exemplary tympanoplasty procedure according to some embodiments. [Figure 14]FIG. 1 is a perspective view of an exemplary reciprocating cutting instrument that may be used to perform the various procedures described herein. [Figure 14A] 15A-15C illustrate the use of the reciprocating cutting instrument of FIG. 14. [Figure 14B] 15A-15C illustrate the use of the reciprocating cutting instrument of FIG. 14. [Figure 14C] 15A-15C illustrate the use of the reciprocating cutting instrument of FIG. 14. [Figure 15] FIG. 10 is an end view of another exemplary cutting instrument that may be used to perform the various procedures described herein. [Figure 16] 16A and 16B illustrate the use of the cutting instrument of FIG. 15. [Figure 16A] 16 is an exemplary cross-sectional view of the cutting instrument of FIG. 15. [Figure 16B] 16 is another exemplary cross-sectional view of the cutting instrument of FIG. 15. DETAILED DESCRIPTION OF THE INVENTION

[0027] Like reference symbols in the various drawings indicate like elements.

[0028] 1, there is shown a conventional transmastoid access to the middle ear 40. The transmastoid approach to the middle ear 40 is used in a variety of therapeutic ear procedures, such as, but not limited to, cholesteatoma removal, labyrinthectomy, cochlear implant placement, and superior semicircular canal dehiscence syndrome repair, to provide a few examples.

[0029] To achieve access to the inner ear 40 using a conventional transmastoid approach as shown, a relatively large amount of tissue is removed from the hollow, air-filled space within the skull behind the ear within the mastoid bone 10. Following this simple mastoidectomy, a small opening into the middle ear 40 is created. The amount of bone removed in the initial simple mastoidectomy is dictated, at least in part, by the limited reach, maneuverability, and size of conventional instruments. Often, even a small-diameter opening into the middle ear cavity 40 requires the removal of a large cone of bone 10 surrounding the opening to allow for a sufficient angle of attack of the instruments relative to the middle ear cavity 40. As indicated by arrows 20a and 20b, the instruments 20 are manually steered along a substantial path to avoid delicate and critical anatomical structures, such as nerves and / or blood vessels, during the procedure.

[0030] Depending on the extent of the surgery required, additional removal of bone 10 beyond a simple mastoidectomy is often necessary. First, a facial recess may need to be created. Second, in some cases, the wall separating the canal wall from the mastoid cavity may need to be removed. Finally, in some cases, bones of the middle ear, or ossicles, may need to be removed. The need for additional bone removal beyond a simple mastoidectomy is also driven, at least in part, by the limited reach, maneuverability, and size of conventional instruments (represented here by instrument 20) used in ear procedures.

[0031] 2 shows a comparison of a conventional simple mastoidectomy 60 associated with a conventional procedure (as shown and described above) and a minimal mastoidectomy 100 associated with a transmastoid approach using the instruments and techniques described herein. As shown, the minimal mastoidectomy 100 is much smaller. Thus, by reducing the diameter of the opening to the middle ear 40 and / or reducing the primarily cone-shaped volume surrounding the opening to the middle ear 40, removal of much less mastoid bone 10 is required for the transmastoid approach using the instruments and techniques described herein.

[0032] The instruments and techniques described herein may be combined with pre- or intraoperative imaging techniques to further reduce the extent of bone removal required. For example, CT imaging may be used to identify axial access paths to safely drill into the middle ear cavity 40, bypassing critical structures including the semicircular canals, sigmoid sinus, chorda tympani, and facial nerve. One or more drill paths may then be used to pass small-gauge steerable instruments and / or endoscopes into the middle ear cavity 40 through channels drilled along these access paths.

[0033] Another potential benefit is that the instruments and techniques described herein can help eliminate the need for additional bone removal beyond a simple mastoidectomy. In particular, in many cases, a posterior canal wall-removal mastoidectomy can be avoided. In traditional, more invasive posterior canal wall-removal mastoidectomy, the posterior upper wall of the ear canal is removed during surgery to enhance access to the middle ear 40 and mastoid process. Converting what is typically a posterior canal wall-removal mastoidectomy to a posterior canal wall-preserving mastoidectomy preserves a significant portion of the patient's anatomy and also eliminates the additional procedural steps associated with grafting and reconstructing the canal wall. Similarly, recovery time, treatment costs, and potential complications are all potentially reduced. In some cases, the instruments and techniques described herein allow some procedures to be performed entirely through the ear canal, completely eliminating the need for transmastoid access. Instead, access can be achieved through various transcanal approaches, the most invasive of which (when elevation of the canal-cutaneous tympanic membrane flap is required) requires minimal or no bone removal for access compared to the transmastoid approach.

[0034] 3 shows an exemplary instrument 120 being used to perform a simple minimal mastoidectomy 100 transmastoid approach as described herein. The exemplary instrument 120 is broadly representative of all of the various types of instruments described herein.

[0035] As will be further described below, some of the features of the instruments 120 that facilitate a minimal mastoidectomy 100 transmastoid approach include small gauge shafts, flexible shafts, steerable / deflectable shafts, angled shafts, curved shafts, etc., and combinations thereof. Additionally, as will be further described below, the instruments 120 include various types of specialized instruments for high speed cutting, aspiration, irrigation, diathermy, ultrasound delivery, laser delivery, pharmaceutical injection, emulsification, etc.

[0036] 4 illustrates an exemplary procedure for treating a cholesteatoma or soft tissue lesion 50, according to some embodiments. That is, minimally invasive debulking of the cholesteatoma or soft tissue lesion may be performed using the instruments and techniques described herein.

[0037] In the illustrated example, an exemplary injection device 300 is used to inject a therapeutic agent into the cholesteatoma 50. In some embodiments, the injected therapeutic agent may be, but is not limited to, a keratolytic agent (e.g., to destroy epithelial tissue), an immune response modifier, a cryotherapy agent, or the like. Such agents may be administered in conjunction with a surgical procedure to help facilitate tissue removal. Such agents may also be administered after surgical removal to reduce the risk of lesion regrowth. In some cases, these agents may be administered via a sustained-release middle ear implant or formulation. The combination of approaches may be uniquely effective by combining the benefits of both approaches without substantially increasing risk to the patient.

[0038] In some cases, the illustrated procedure for treating cholesteatoma (or debulking other soft tissue lesions) may be performed periodically, e.g., every few years. This can be surprisingly beneficial for several reasons. The availability of minimally invasive visualization allows for identification of cholesteatoma or other lesions much earlier in the disease course (before the patient reports symptoms), which typically means smaller or less advanced lesions. Cholesteatoma originates from the epithelium in the tympanic membrane or external auditory canal. As it grows, it often extends down to the ossicles and may eventually invade the mastoid bone, inner ear, facial nerve, or intracranial compartment. The extent of the cholesteatoma determines the level of invasiveness required for successful removal. Therefore, early detection and management can minimize the need for more invasive surgical procedures and the more serious consequences of the disease, such as ossicular erosion requiring prosthetic reconstruction. Additionally, typical existing procedures must be highly invasive because there is a high level of concern about missing any cholesteatoma, which may regrow and require repeated invasive procedures. The ability to minimally invasively debulk cholesteatoma changes the risk / benefit ratio so that care strategies can intervene earlier and more frequently, which surprisingly poses less overall risk to the patient than a single invasive procedure.

[0039] While injection of a therapeutic agent to treat cholesteatoma 50 is shown, other techniques and associated instruments for treating cholesteatoma 50 may be used and are within the scope of this disclosure. For example, in some embodiments, instrument 300 may be an ultrasonic instrument that may be used to emulsify cholesteatoma 50. In another example, in some embodiments, instrument 300 may be a high-speed cutting instrument that can physically dissect portions of cholesteatoma 50. In another example, in some embodiments, instrument 300 may be a diathermy instrument, which is particularly beneficial in the management of highly vascular glomus tumors for severing vasculature and managing intraoperative bleeding. In another example, in some embodiments, instrument 300 may be a laser instrument.

[0040] Instrument 300 can include small gauge shafts, flexible shafts, steerable / deflectable shafts, angled shafts, curved shafts, etc., and combinations thereof. The improved reach and visualization provided by these instruments from a canal-based approach to the middle ear allows for greater extent of cholesteatoma removal without the need for more invasive access approaches. Furthermore, in some embodiments, instrument 300 can have multiple purposes, such as a combination of functions including, but not limited to, suction, illumination, irrigation, endoscopy, diathermy, laser energy delivery, injection, ultrasonic emulsification, etc.

[0041] The illustrated minimally invasive procedure for treating cholesteatoma 50 uses a transtympanic approach (e.g., through the area of ​​the tympanic membrane 30). In some implementations, the transtympanic approach involves extending an instrument shaft through an opening (e.g., a puncture, a slit, a perforation, etc.) in the tympanic membrane (TM) 30. In certain implementations, the illustrated minimally invasive procedure for treating cholesteatoma 50 uses a canal cutaneous tympanic membrane flap procedure, whereby an instrument shaft is extended through the ear canal 25 to the cholesteatoma 50 without passing through the TM 30.

[0042] In certain implementations, a transtympanic approach for a minimally invasive procedure to treat cholesteatoma 50 includes extending an instrument shaft through a tympanic membrane port device 200 (TM port device 200) shown in FIGS. 4A and 4B . The exemplary TM port device 200 includes three connected, continuous sections: (i) a distal end section 204, (ii) an intermediate section 206, and (iii) a proximal end section 208. A lumen 202 runs through the center of each of sections 204 / 206 / 208. In some embodiments, lumen 202 has a diameter ranging from, but not limited to, 0.4 mm to 0.6 mm, 0.5 mm to 0.75 mm, or 0.5 mm to 1.0 mm.

[0043] The inner diameter or lumen of proximal portion 208 may be tapered to have a larger diameter at the proximal end, creating a funnel shape that facilitates alignment of instruments as they enter the port device.

[0044] The distal end portion 204 may be frusto-conical in shape. That is, the distal-most end of the distal end portion 204 has a smaller outer diameter than the proximal-most end of the distal end portion 204. The intermediate portion 206 and the proximal end portion 208 are each cylindrical. The outer diameter of the intermediate portion 206 is smaller than the outer diameter of each of (i) the proximal-most end of the distal end portion 204 and (ii) the proximal end portion 208. Thus, the intermediate portion 206 may be considered the "waist region" of the TM port device 200 in this embodiment. The lumen 202, like the distal end portion 204, may be conical, cylindrical, oval, pyramidal, or other shape.

[0045] As described further below, the intermediate portion 206 is where the tissue of the TM 30 resides (at least primarily) while the TM port device 200 is implanted within the TM 30. The relatively small outer diameter of the intermediate portion 206 (compared to the outer diameters of the adjacent portions of the distal end portion 204 and proximal end portion 208) facilitates placement of the TM port device 200 within the TM 30. In some embodiments, the outer diameter of the intermediate portion 206 ranges, without limitation, from 0.25 mm to 0.75 mm, from 0.25 mm to 1.0 mm, or from 0.5 mm to 1.25 mm. The longitudinal length of the intermediate portion 206 can range, without limitation, from 0.1 mm to 0.3 mm, from 0.1 mm to 0.5 mm, or from 0.2 mm to 0.6 mm. The outer diameter and length of the intermediate portion 206 are sufficient to accommodate the thickness of the TM 30 while preventing inadvertent buckling, tearing, or other forces from being applied to the TM 30 during insertion of the TM port device 200. In some embodiments, a waist region is not included, and the friction fit between the distal section and the TM is sufficient to hold the port device within the TM during the procedure while reducing forces to which the TM is exposed during port insertion or removal.

[0046] In some embodiments, the TM port device 200 can be implanted within the TM 30 without the use of a trocar needle. Instead, an incision in the TM 30 can first be made using a blade, needle, or laser. The TM port device 200 can then be implanted within the TM 30 by advancing the TM port device 200 into the incision.

[0047] While the TM port device 200 is implanted (or attached, coupled, engaged, etc.) to the TM 30, the TM port device 200 functions as a grommet, a stress relief member to prevent tearing of the TM 30, a middle ear access port, an instrument insertion tunnel, a working channel, etc.

[0048] The TM port device 200 is configured and sized so that removal of the TM port device 200 from the TM 30 does not require the use of sutures to seal the incision or fenestration formed in the TM 30 during insertion of the TM port device 200. Generally, the self-sealing fenestration through the TM 30 is no more than about 2.5 mm in length, and preferably between about 0.5 mm and 1.5 mm in length. While the tools and methods described herein provide the advantage of sutureless access to the middle and / or inner ear, this does not preclude a surgeon from applying one or more closure techniques upon removal of the TM port device 200. That is, if the clinician desires, one or more techniques for closure of the fenestration in the TM 30 may be performed.

[0049] The TM port device 200 can be formed from a material that has the rigidity and strength to be inserted into and removed from the TM 30 while withstanding stresses that may occur during manipulation of the inserted surgical instrument. In some embodiments, at least a portion of the TM port device 200 is formed from a surgical metal, such as stainless steel, titanium, platinum, or nitinol, and / or a plastic, such as polyimide, PEEK, fluoropolymer, or silicone. In some embodiments, the insertion portion of the TM port device 200 can be formed from polyimide (or other rigid or semi-rigid polymer) and can have a maximum outer diameter of about 20 gauge (0.8 mm) or less. One or more portions of the TM port device 200 can be coated with or formed from a resilient, conformable material.

[0050] 5 illustrates another exemplary procedure for treating cholesteatoma 50, according to some embodiments. That is, minimally invasive cholesteatoma debulking may be performed using the instruments 400 and techniques described herein.

[0051] For example, in some embodiments, the exemplary instrument 400 may be an ultrasonic instrument that may be used to emulsify the cholesteatoma 50. In another example, in some embodiments, the instrument 400 may be a high-speed cutting instrument that may physically remove a portion of the cholesteatoma 50. In yet another example, in some embodiments, the instrument 400 may be a diathermy instrument or a laser instrument that may ablate a portion of the cholesteatoma 50.

[0052] The instrument 400 can include a small gauge shaft, a flexible shaft, a steerable / deflectable shaft, an angled shaft, a curved shaft, etc., and combinations thereof. Additionally, in some embodiments, the instrument 400 can have multiple purposes, such as a combination of functions including, but not limited to, aspiration, illumination, irrigation, endoscopy, diathermy, laser energy delivery, injection, ultrasonic emulsification, etc.

[0053] In some embodiments, an exemplary instrument 400 for minimally invasively treating cholesteatoma 50 may be, for example, an ultrasonic instrument. Such an ultrasonic instrument 400 may be used to deliver ultrasonic energy to cause fragmentation, emulsification, or resurfacing of tissue, such as, but not limited to, membranes, tumors, cholesteatoma, skin, bone, etc. This technique may be beneficial for controlling bleeding and, in some embodiments, for enabling the use of suction ultrasonic instruments (e.g., suction high-speed cutters or diathermy instruments) for tissue removal.

[0054] In some embodiments, the exemplary instrument 400 may be an ultrasonic instrument that can be used to treat cholesteatoma 50. Ultrasonic instruments for bone and tissue removal (e.g., cholesteatoma 50) may be combined / incorporated with any of the otic instruments described herein. That is, a small-gauge ultrasonic instrument with suction and injection to remove debris may be used to remove small areas of bone adjacent to the facial nerve and other delicate structures. Such an instrument may be used to help debride bone from soft tissue, as in the case of cholesteatoma 50 removal. The ability of an ultrasonic instrument to be "tuned" to remove specific tissue densities may be highly advantageous for improving tissue removal selectivity in cholesteatoma 50 removal.

[0055] In some embodiments, the exemplary instrument 400 may be a laser instrument that can be used to treat cholesteatoma 50. Laser instruments may be combined / incorporated with any of the otic instruments described herein. Laser-based methods are a useful modality of surgical intervention that currently sees limited use in otics. Green lasers may be particularly useful because they typically apply heat only where loose / exposed blood (due to blood pigmentation) is present, allowing for heating and ablation of blood without damaging underlying or adjacent tissue. These instruments have had limited use in otics for a variety of reasons, including difficulty accessing the middle or inner ear region and bony middle ear structures blocking a straight-line angle of attack to the desired target. In some embodiments, a functional tip laser probe with a tip that can be actuated to generate steerability or functionality off-axis from an adjacent shaft would be highly advantageous and could enable entirely new functionality for otic procedures.

[0056] FIG. 6 illustrates an exemplary minimally invasive procedure for addressing otosclerosis, thereby replacing current treatments such as stapedectomy and stapes surgery, according to some embodiments. The instruments and techniques for performing the procedure facilitate precise removal of the ossification buildup around the stapes footplate, known as otosclerosis. Such a procedure removes stapes superstructures and restores stapes footplate mobility without drilling holes in the stapes footplate (stapedectomy) or completely removing the footplate (stapedectomy). The described instruments allow precise visualization and access to the stapes footplate, minimize incidental bone removal, and obviate the need for prosthetic reconstruction of the ossicular chain required with current stapedectomy and stapes surgery.

[0057] In some embodiments, the procedure time and outcomes of standard stapedectomies and stapes surgeries may be improved with the instruments and techniques described herein. In one example, side-biting disposable scissors may be used to sever the stapedius tendon. Typically, in stapedectomies and stapes surgeries, bone removal at the lateral wall is required to allow visualization and instrument access. In another example, using steerable, small-gauge instruments and wide-field visualization systems, bone removal may be minimized or avoided, shortening procedure time and reducing the risk of collateral tissue damage. Removal of the lateral wall is typically performed with curettes, which are difficult to precisely control and pose a risk to adjacent tissue. In yet another example, more precise bone removal may be achieved with ultrasonic instruments, thereby reducing the risk of injury to adjacent nerves.

[0058] Here again, the procedure is shown as being performed by an exemplary instrument 400 (which, as described herein, represents several different types of instruments and instrument combinations).

[0059] In some cases, the instruments and techniques described herein can allow procedures to be performed minimally invasively via transcanal 25 and transtympanic approaches due to avoiding the need for smaller diameter instruments and removal of implants and ossicles (which may not fit through minimally invasive access ports or incisions). This obviates the need for transcanal 25 approaches, such as those requiring canal-cutaneous tympanic flap elevation, thereby reducing patient risk and procedure time.

[0060] For example, in some embodiments, an exemplary instrument 400 for performing a minimally invasive stapedectomy procedure is a green laser with a steerable tip, suction, and illumination. In some embodiments, an exemplary instrument 400 for performing a minimally invasive stapedectomy procedure is the ultrasonic emulsifier described above.

[0061] The instrument 400 can include a small gauge shaft, a flexible shaft, a steerable / deflectable shaft, an angled shaft, a curved shaft, etc., and combinations thereof. Additionally, in some embodiments, the instrument 400 can have multiple purposes, such as a combination of functions including, but not limited to, aspiration, illumination, irrigation, endoscopy, diathermy, laser energy delivery, injection, ultrasonic emulsification, etc.

[0062] In some embodiments, the exemplary instrument 400 ( FIG. 6 ) for performing a minimally invasive procedure to address otosclerosis is a high-speed cutting device, such as the exemplary pneumatic suction cutter 1100 shown in FIG. 14 . In some embodiments, the pneumatic suction cutter 1100 may be electrically (rather than pneumatically) driven. The pneumatic suction cutter 1100 includes an outer shaft 1110 and an inner reciprocating shaft 1120. The inner reciprocating shaft 1120 reciprocates proximally and distally within a lumen defined by the outer shaft 1110. Thus, as shown in FIGS. 14A-14C , tissue can be cut between the outer shaft 1110 and the inner reciprocating shaft 1120 (e.g., in the manner of a “guillotine” blade cutter). Once a portion of tissue is cut, the tissue portion can be aspirated through the pneumatic suction cutter 1100, as shown.

[0063] The pneumatic suction cutter 1100 may be useful for a variety of applications, such as, for example, stapedectomy, removal of middle ear tissue, and resurfacing or freshening the edges of a tympanic membrane perforation in a tympanoplasty procedure (e.g., a tympanic membrane repair procedure, as described further below).

[0064] 6, the use of the pneumatic suction cutter 1100 for minimally invasive procedures to address otosclerosis (or other procedures) may also be combined with fluid infusion or flooding of the middle ear and / or ear canal 25. The pneumatic suction cutter 1100 may also have general utility in removing membranes or fibrous tissue within the middle ear.

[0065] In the case of an axially reciprocating blade on the inner reciprocating shaft 1120, the port defined by the outer shaft 1110 is most ideally located on the side of the outer shaft 1110 ("side cutting") so that the target tissue is accessible to the side of the instrument tip. For example, this orientation may be preferable when debriding around a tympanic membrane perforation in preparation for implant placement or repair. Side cutting ports may also be ideal for removing earwax from the wall of the ear canal 25.

[0066] 15-16B illustrate another exemplary high-speed cutter that may be used in the minimally invasive procedure for addressing otosclerosis shown in FIG. 6, as well as other ear procedures described herein. The functionality of the rotary suction endocutter 1900 may be combined with or incorporated into any of the otic instruments described herein.

[0067] The high-speed rotary suction endocutter 1900 includes an outer shaft 1910 and an inner rotary shaft 1920. The inner rotary shaft 1920 rotates within a lumen defined by the outer shaft 1910. The end of the outer shaft 1910 defines an opening 1912 through which tissue can be received. In the illustrated embodiment, the opening 1912 is a circular segment (e.g., a quarter circle, a semicircle, etc.). Thus, as shown in FIG. 16 , once tissue is captured within the opening 1912, it can be cut between the outer shaft 1910 and the inner rotary shaft 1920 (e.g., in the manner of a “rotary shear” blade cutter). Once a portion of the tissue is cut, it can be aspirated through the high-speed rotary suction cutter 1900, as shown.

[0068] The high-speed rotary suction endocutter 1900 may be useful, for example, in minimally invasive procedures to address otosclerosis as shown in Figure 6, in removing middle ear soft tissue, in cutting back the epithelial margin around the edge of a tympanic membrane perforation in a tympanoplasty procedure (e.g., a tympanic membrane repair procedure as described below), etc. The high-speed rotary suction endocutter 1900 may also have general utility in removing membranes or fibrous tissue within the middle ear.

[0069] The tip of the illustrated high speed rotary suction endocutter 1900 is blunt, however, in some embodiments, the tip may be beveled, conical, rounded, or the like.

[0070] Removal of material (e.g., tissue, bone, etc.) may be performed using the high-speed rotary suction endocutter 1900. Cutting is achieved at the interface of the inner rotating shaft 1920 and the inner wall of the outer shaft 1910 at the location of the opening 1912. The shape and location of the opening 1912 may be configured for optimal contact with the target tissue or substance. Because the cutting action occurs just inside the outer surface of the instrument 1900 (approximately the wall thickness of the outer shaft 1910), the size and suction force of the opening 1912 may be selected to maximize removal of the target material while limiting damage to adjacent tissue. In some embodiments, a suction channel down the center of the instrument 1900 can assist in drawing the target material into the opening 1912 to facilitate cutting. In some embodiments, the level of absorption force and cutting speed of the instrument 1900 may be adjusted based on the mechanical properties of the target and surrounding tissue. Absorption also allows for immediate removal of the cut or shredded material from the surgical field.

[0071] In some cases, such as removing material from the bone surface of the middle ear for stapes surgery, it is advantageous to place the cutting action at the end of the instrument ("end cutting"), as provided by the high-speed rotary suction endocutter 1900. In such cases, a rotary blade is preferred. In this case, the tip of the instrument may be blunt, rounded, beveled, or conical in shape, and the shape and orientation of the cutting blade mirrors the shape and orientation of the opening 1912 to achieve an effective shear or scissor-like cut.

[0072] 16B shows an alternative inner rotatable shaft 1920a. In this example, the inner rotatable shaft 1920a has two end openings or cutting edges. The two end openings provide two tissue cuts per revolution (compared to the one tissue cut per revolution provided by the inner rotatable shaft 1920).

[0073] The high-speed rotary suction endocutter 1900 is appropriately sized for the application. In some embodiments, the outer diameter of the high-speed rotary suction endocutter 1900 ranges from 0.4 mm to 4 mm, preferably less than 2 mm in diameter. The distal shaft portion that is inserted into the ear canal 25 is 25-70 mm in length, preferably approximately 50 mm in length. The handle is preferably smaller in diameter so as not to obstruct visualization of the target area. The handle can be angled or curved relative to the distal shaft, or the distal shaft itself can have a curve.

[0074] In some embodiments, an exemplary instrument 400 for performing minimally invasive stapes surgery ( FIG. 6 ) and / or other ear procedures described herein is an exemplary coaxial bipolar diathermy instrument 1000 shown in FIG. 11 . The coaxial diathermy instrument 1000 includes a probe 1010 and a distal tip 1020 containing electrodes for delivering heat. The use of the coaxial principle allows current to flow only at the end face of the probe, which allows essentially hyperthermic functions to be localized at the very distal tip 1020 of the probe 1010. It provides a compact, end-on coagulation effect, and when used with a low-frequency diathermy unit, allows such probes to be used safely in close proximity to delicate tissue. Bipolar diathermy instruments are used externally within the canal 25 in otology, but are, and have been, too large and imprecise for middle ear surgery. Existing diathermy instruments in the otology field are not used in middle ear procedures for a variety of reasons, including the difficulty of accessing the middle or inner ear region and the bony structures of the middle ear blocking a straight-line angle of attack to the desired target.

[0075] In some embodiments, the probe 1010 is deflectable or steerable (as described above) for off-axis functionality. In other embodiments, suction functionality may be included within the same instrument to remove loose blood or thin clots from actively bleeding vessels and then immediately coagulate them. This coaxial diathermy instrument 1000 is highly advantageous and enables entirely new capabilities for otologic procedures.

[0076] Figure 12 shows optional modifications of the coaxial bipolar diathermy instrument 1000. Diathermy itself is a useful modality for surgical interventions not currently used in otology, whether in mastoid / open access procedures, ear canal, middle ear, or inner ear applications. The addition of other features to diathermy increases its usefulness beyond what might be expected.

[0077] One additional useful feature that can be optionally added to the coaxial bipolar diathermy instrument 1000 is the addition of illumination (indicated by light beam 1022). The diathermy instrument 1000 can have a light source attached to the distal tip or an optical fiber carrying light to the distal tip. Proper illumination can be problematic in otologic procedures, especially if the instrument handle obstructs the light source during use. The middle ear and surrounding anatomical structures are composed of many small, complex structures that create corners that block visualization and, in turn, illumination. Having onboard illumination on the diathermy probe instrument 1000 greatly enhances its range of use as well as ease of use. The ability to control the light source close to the target tissue also minimizes the possibility of glare resulting from reflections from other surfaces, such as the tympanic membrane. Movement of the light source during operation can also cast shadows, allowing for easier identification of anatomical structures.

[0078] Another additional useful feature that may be optionally added to the coaxial bipolar diathermy instrument 1000 is suction (indicated by arrow 1024). Diathermy may be primarily useful for controlling bleeding as a method of cauterizing small blood vessels within the middle ear cavity or ear canal 25. Adding suction functionality allows for the "one-handed" ability to cauterize blood vessels while clearing blood and other cauterized tissue from the surgical field. This two-part ability to manage bleeding greatly facilitates the clinician's ability to quickly control bleeding, thereby minimizing procedure time, minimizing instrument changes and the associated risk of tissue damage, reducing the number of personnel and hands required in the surgical field, and overall facilitating a burdensome task encountered in most surgical procedures.

[0079] The use of the coaxial bipolar diathermy instrument 1000 in combination with built-in lighting 1022 and / or suction 1024 creates a one-handed instrument 1000 well suited for use in otologic procedures, such as minimally invasive stapes surgery and other procedures described herein, with value far greater than the predicted sum of its individual functions.

[0080] 7-8 illustrate an exemplary minimally invasive Eustachian tube treatment technique according to some embodiments. The proximity of the Eustachian tube 42 to the carotid artery or other sensitive structures makes surgery potentially risky. Ear infections are a particularly common problem, and the common treatment of using a tympanostomy tube 80 to create an opening in the tympanic membrane 30 is an incomplete solution to the fluid accumulation ultimately caused by Eustachian tube blockage. Therefore, the illustrated minimally invasive Eustachian tube 42 treatment is an advantageous technique that can address the underlying cause of most ear infections. Additionally, using either transcanalicular 25 access, tympanostomy ear drainage tube access, ports, or minimally invasive access methods can facilitate procedures that can be performed in an office setting without general anesthesia, expanding the possibilities for the described methods. Another advantage is that the access path is potentially much shorter and less tortuous, dramatically reducing the difficulty of constructing a delivery system that can reach the target area compared to catheters that must navigate a long, tortuous nasopharyngeal approach. The ability to minimally invasively access the Eustachian tube 42 via a transcanal 25 approach can be advantageous as it eliminates or reduces many of the delivery issues that have prevented the direct treatment of most Eustachian tube 42 obstructions or dysfunctions from gaining acceptance and allows for new methods of targeted delivery directly to the Eustachian tube 42 and adjacent areas.

[0081] Here, a tympanostomy ear drainage tube 80 (or a temporarily placed TM port device 200 as shown in FIGS. 4A-4B ) provides access to the middle ear 40 (which is filled with fluid in this example) via the TM 30. That is, the distal end portion of the balloon catheter device 500 can be extended into the middle ear 40 such that the balloon 520 of the balloon catheter device 500 is positioned within the Eustachian tube 42. During advancement of the balloon catheter device 500, the balloon 520 is in a deflated state. Specifically, the deflated balloon 520 is positioned within a non-bony portion of the Eustachian tube 42 (e.g., the elastic cartilage portion of the Eustachian tube 42, i.e., the lower two-thirds adjacent to the nasopharynx).

[0082] In some embodiments, the distal tip portion of the balloon catheter device 500 is steerable to assist in the placement of the deflated balloon 520 within the Eustachian tube 42. With the deflated balloon 520 positioned within the Eustachian tube 42, the balloon 520 can be inflated to radially expand the balloon 520. The resulting expansion of the Eustachian tube 42 from the expansion of the balloon 520 stretches the inside of the Eustachian tube 42, leading to healing with a thin layer of fibrous scar tissue that helps hold the Eustachian tube 42 open and increases the size of the lumen of the Eustachian tube 42, which helps promote drainage. In some embodiments, the balloon 520 can be coated with a drug. In some embodiments, the balloon 520 can deliver a stent that holds the Eustachian tube 52 open. In some such embodiments, the stent can be a drug-eluting stent. In some such embodiments, the stent can be a bioabsorbable stent. A stent can be a more durable solution to Eustachian tube obstruction than a tympanostomy tube 80.

[0083] The tympanostomy ear drainage tube 80 (or the temporarily placed TM port device 200 as shown in FIGS. 4A-4B) may be constructed in whole or in part of a resorbable material that allows the tube or port to dissolve and / or fall off over time, minimizing the risk of tissue damage during physical removal. Examples of resorbable materials include polylactide and collagen scaffolds.

[0084] Referring to FIG. 9 , in a similar access / approach method (e.g., via the ear canal 25), a tympanotomy ear drainage tube 80 (or TM port device 200) creates a ready access point for delivery of sprays, gels, therapeutic agents, gene delivery, antibiotics, antimucosal agents, surfactants, dilators or adrenaline, devices, etc., to the middle ear 40 and / or Eustachian tube 42. A cannula or needle 600 can be used to deliver gels or liquids to which antibiotics, antihistamines, decongestants, mucus thinning / expectorants, dilators or adrenaline, surfactants, etc. can be added. Such a needle or cannula 600 can incorporate any / all of the features of the instruments described herein (e.g., small gauge shaft, flexible shaft, steerable / deflectable shaft, angled shaft, curved shaft, and / or combinations of functions including, but not limited to, suction, illumination, irrigation, endoscopy, diathermy, laser energy delivery, injection, ultrasonic emulsification, etc.). For example, the tympanotomy ear drainage tube 80 (or TM port device 200) allows for precise, direct intratympanic delivery of therapeutic agents to the tympanic end of the Eustachian tube 42 to treat Eustachian tube dysfunction. Precise delivery of therapeutic agents to the middle ear for the treatment of Eustachian tube dysfunction can be achieved with formulations containing surfactants, such as, but not limited to, dipalmitoylphosphatidylcholine [DPPC], beractant, calfactant, poractant alfa, simethicone, and betahistine. In contrast to the well-described intranasal approach to treating Eustachian tube dysfunction, middle ear 40 access provides access to a natural reservoir within the inferior tympanum, closer to the isthmus or osteochondral junction, potentially allowing for a longer, sustained release of therapeutic agents to modify the surface tension of the Eustachian tube 42 and enhance its opening, so that middle ear ventilation can be restored.

[0085] 10 , in some embodiments, the procedures described herein, as well as other ear procedures, may be advantageously performed by flooding the middle ear 40 and / or outer ear 25. The cavity of the middle ear 40 is normally filled with air. A liquid (e.g., saline, water, etc.) may be used to temporarily fill the cavity of the middle ear 40 so that the therapeutic procedures described herein may be performed "underwater." This approach offers several advantages.

[0086] During cochlear implant electrode placement, one of the fluid-filled compartments of the cochlea, the scala tympani, is intentionally breached. This can result in loss of perilymph fluid leaking into the air-filled middle ear 40, potentially leading to dizziness and / or permanent damage to the delicate cellular structures of the cochlea. Filling the middle ear 40 cavity with an artificial perilymph-like fluid (e.g., protein-rich artificial cerebrospinal fluid) or a sodium hyaluronate-based viscoelastic (e.g., Healon, DuoVisc, ProVisc, or Viscoat) can maintain fluid equilibrium in the cochlea during surgery.

[0087] When performing middle or inner ear surgery (e.g., cholesteatoma surgery or stapedectomy), the round window membrane or oval window can be inadvertently disrupted, resulting in a loss of perilymphatic fluid that can leak into the air-filled middle ear 40, leading to dizziness and permanent damage to the delicate cellular structures of the cochlea. Filling the middle ear 40 cavity with an artificial perilymph-like fluid (e.g., protein-rich artificial cerebrospinal fluid) or a sodium hyaluronate-based viscoelastic (e.g., Healon, DuoVisc, ProVisc, or Viscoat) can maintain fluid equilibrium in the cochlea during surgery.

[0088] Performing a cochlear fenestration procedure to place cochlear implant electrodes, access the inner ear cavity for the treatment of neuromas or schwannomas, or for any other reason can result in the loss of perilymph, leading to dizziness and permanent damage to the delicate cellular structures of the cochlea. Filling the middle ear 40 cavity with an artificial perilymph-like fluid (e.g., high-protein artificial cerebrospinal fluid) or a sodium hyaluronate-based viscoelastic (e.g., Healon, DuoVisc, ProVisc, or Viscoat) can maintain fluid balance in the cochlea during surgery. Intraoperative bleeding within the middle ear space 40 must always be managed during surgical procedures. Maintaining a fluid-filled compartment in the middle ear 40 can help tamponade bleeding, especially when heavy fluids such as sodium hyaluronate-based viscoelastics (e.g., Healon, DuoVisc, ProVisc, or Viscoat) or silicone oil are used. Alternatively, the fluid may contain a hemostatic agent to further reduce bleeding.

[0089] Maintaining a constant infusion of simple saline or artificial perilymph-like fluid in the middle ear 40 may allow for suction procedures to be performed, allowing for constant irrigation or flushing of the ear structures. Antioxidant additives, such as glutathione, may also be added to the irrigation solution to minimize intraoperative and postoperative inflammation. This may be beneficial in controlling bleeding and enabling the use of suction-assisted ultrasonic instruments and suction-assisted pneumatic cutters for tissue removal. In some embodiments, these instruments can provide simultaneous infusion and suction. Simultaneous infusion and suction minimizes frequent instrument changes and allows for more efficient removal of blood and other debris. This exchange is particularly beneficial in the removal of cholesteatoma, where complete removal of the moist epithelial tissue is important to minimize the risk of recurrence.

[0090] An endoscope can be used to allow visualization of the fluid-filled middle ear 40. Using an endoscope in a fluid-filled space eliminates the concern or difficulty of cloudiness or blood obscuring the lens and the subsequent need to clean the endoscope lens. Alternatively, a lens can be placed at the air / liquid interface (similar to a swim mask) to allow visualization via a microscope. The lens can have ports through it or around it to allow for the penetration of instruments. In some embodiments, such lenses can be made to provide a wide viewing angle.

[0091] In the case of tympanoplasty, it may be advantageous to fill all or part of the ear canal 25 with fluid in addition to the middle ear cavity 40. This provides additional mechanical support to the tympanic membrane 30 and allows a suction cutter to be used to trim the edges of the perforation.

[0092] 10 , in the illustrated example, a TM port or lens assembly 210 is temporarily positioned within the TM 30. In some embodiments, the TM port or lens assembly 210 is a TM port 210. Alternatively, in some embodiments, the TM port or lens assembly 210 is a TM lens assembly 210 (for viewing into the middle ear 40).

[0093] The TM lens assembly 210 includes a frustoconical proximal portion that extends into the outer ear 25. In this example, the frustoconical proximal portion of the TM lens assembly 210 functions as a dam, allowing partial flooding of the outer ear 25 (e.g., down to level 26) while ensuring that the proximal surface of the TM lens assembly 210 remains dry. The use of an open passage between the middle ear and the outer ear (either through an incision, an open or valved TM port 210, or other means) allows any excess fluid within the middle ear to exit without creating high pressure within the middle ear 40, partially filling the ear canal 25 or tubular member as an overflow or excess, thereby facilitating regulation of the fluid volume / pressure within the middle ear 40 without the need for additional, potentially complex equipment. By controlling the fluid level in the tubular member 25 combined with this frustoconical feature, a lens / water interface at the lens distal surface and a lens / water interface at the lens proximal surface are maintained, allowing optimal light transmission to an externally located surgical microscope.

[0094] In some embodiments, the TM port or lens assembly 210 is a TM port for accessing the middle ear 40. A "wall" or "funnel" surrounding the TM port can be used in combination with a valved port to keep the proximal port surface dry. This has the advantage of preventing potential contamination of middle ear irrigation fluid when inserting instruments through the port. Another advantage of keeping the TM port surface dry is that it maintains visibility of the port for easier instrument targeting.

[0095] In some embodiments, a suction device 220 (or a speculum with suction capabilities) is used in the outer ear 25 to control the level 26 of fluid within the outer ear 25 (or to completely remove fluid from the outer ear 25). The suction device 220 can be a wicking or typical suction-driven suction device.

[0096] In certain embodiments, the TM port 210 includes one or more valves to restrict the drainage of fluid into the outer ear 25. The TM port 210 can also include various valves / openings for instruments, ports for visualization, suction, irrigation, etc.

[0097] Conversely, the valve may be unidirectional to limit fluid entry into the middle ear 40, so as to prevent fluid from exiting the middle ear 40 and returning through the valve. As an example, this would direct the flow of infusion fluid from the middle ear 40 into the canal 25, minimizing potential contamination of the fluid within the middle ear 40 from fluid contacting the skin of the canal 25.

[0098] In another exemplary embodiment, the TM port or lens assembly 210 can have one or more side channels to allow bidirectional flow and "drainage" of excess fluid from the middle ear 40.

[0099] In another exemplary embodiment, the TM port 210 may be connected to a primarily tubular member extending proximally outward from the port, which may serve as an overflow reservoir for any excess fluid within the middle ear 40 to drain without creating high pressure within the middle ear 40, thereby facilitating regulation of fluid volume / pressure within the middle ear 40 and eliminating the need for valves or walls in other lenses or ports used during the same procedure. Such a tubular member may thereby be connected to a lateral flow or suction device at a given height above the port site to maintain a given pressure determined by the head height of the lateral flow.

[0100] While the isthmus may be constricted during fluid-filled procedures (the Eustachian tube is typically closed except during chewing, swallowing, or yawning), thereby allowing fluid to fill the middle ear, it is envisioned that the devices described herein (e.g., small gauge shafts, flexible shafts, steerable / deflectable shafts, angled shafts, curved shafts, and / or combinations of features including, but not limited to, suction, illumination, irrigation, endoscopy, diathermy, laser energy delivery, injection, ultrasonic emulsification, etc.) can stimulate constriction of the isthmus and thereby allow localized delivery of agents (such as vasoconstrictors or prokinetic agents) to allow fluid filling of the middle ear space. In other embodiments, the isthmus may be mechanically sealed, such as with a temporarily placed balloon catheter or a brief, resorbable gel (e.g., formulated to dissolve over a timescale of several hours).

[0101] Conversely, it is contemplated that in some cases, it may be advantageous to ensure that the Eustachian isthmus is not constricted or remains open to provide for drainage of the middle ear space following treatment using a fluid-filling technique. It is contemplated that the devices described herein (e.g., small gauge shafts, flexible shafts, steerable / deflectable shafts, angled shafts, curved shafts, and / or combinations of features including, but not limited to, suction, illumination, irrigation, endoscopy, diathermy, laser energy delivery, injection, ultrasonic emulsification, etc.) may achieve dilation or opening of the Eustachian isthmus, thereby enabling the local delivery of antibiotics, antihistamines, decongestants, mucus thinning / expectorants, dilatants or adrenaline, surfactants, etc., to facilitate fluid drainage of the middle ear space.

[0102] 13 illustrates an exemplary tympanoplasty procedure using exemplary instrument 400. In some embodiments, the tympanoplasty procedure may be performed underwater.

[0103] During a tympanoplasty procedure, the edges of an existing tympanic membrane perforation 31 are first "freshened" by removing tissue surrounding the perforation 31. Currently, there are no precise instruments to perform this procedure, and typically more tissue than necessary is removed, further enlarging the perforation, complicating subsequent patching procedures, and reducing the likelihood of successful closure of the perforation 31.

[0104] In some cases, the exemplary instrument 400 used to perform the tympanoplasty procedure may be a miniature pneumatic "guillotine" blade cutter with suction provided by a pneumatic suction cutter 1100 ( FIG. 14 ). The pneumatic suction cutter 1100 can ensure a more precise cut around the perforation 31 because the TM 30 can be held taut by suction during cutting. Furthermore, the cutting action does not require manual manipulation, as with scissors, so that precise cutting can be controlled simply by guiding the position of the instrument's cutting port to the target tissue. Thus, the miniature pneumatic "guillotine" blade cutter with suction provided by the pneumatic suction cutter 1100 can ensure a more precise cut around the perforation 31. In some embodiments, this cutting may also be combined with fluid infusion or flooding of the middle ear 40 and / or ear canal 25. The pneumatic suction cutter 1100 may also have utility in removing membranes and fibrous tissue within the middle ear 40.

[0105] Various other types of instruments 400 may be used for the tympanoplasty procedure. For example, in some embodiments, an ultrasonic instrument, scraper, or endocutter (FIGS. 15-16B) may be used to remove the epithelial surface tissue surrounding the perforation 31.

[0106] Although the instruments disclosed herein are primarily described in the context of otologic procedures using either an outer ear or a transcanal or transtympanic approach to the middle or inner ear, it should be understood that the instruments are not limited to such applications and may be used in other cavities or spaces within the body and for other approaches. For example, in some embodiments, the instruments described herein may be used for other approaches and techniques to the middle ear, inner ear, Eustachian tube, or mastoid sinus space, including, but not limited to, transmastoid access, transcanal via a canal-cutaneous tympanic flap, transtympanic annulus, intraaural, retroaural, postaural, and others. Such systems and methods may be used for drug delivery, gel delivery, antibiotic delivery, gene delivery, graft delivery, device or implant delivery, tissue removal, diagnostic procedures, sampling procedures, and surgical procedures.

[0107] It should be noted that any of the embodiments or features of the embodiments described herein may be combined in any combination and any permutation, all within the scope of the present disclosure.

[0108] The devices, systems, and methods described herein may be used in the process of treating any disorder of the middle and / or inner ear, including, but not limited to, hearing loss, tinnitus, balance disorders including dizziness, Meniere's disease, vestibular neuritis, vestibular schwannoma, labyrinthitis, otosclerosis, ossicular chain luxation, cholesteatoma, otitis media, middle ear infection, and tympanic membrane perforation, to provide a few examples. In some embodiments, the devices, systems, and methods described herein may be used in the process of precise delivery of therapeutic agents to the round window fossa and / or other target sites, such as the oval window or other parts of the middle ear cavity, as well as to provide access to other features or regions of the middle ear. For example, the systems and methods described herein may be used for minimally invasive surgical reconstruction of the ossicular chain, cholesteatoma removal, diagnostic evaluation, and other procedures. Any and all such techniques for using the systems and methods described herein are within the scope of this disclosure.

[0109] The devices and systems described herein may be constructed of metals such as, but not limited to, aluminum, titanium, stainless steel, or polymers such as, but not limited to, ABS, PEEK, PET, HDPE, injection molded components, etc. Components such as flexible rings may be constructed of elastomeric materials, gels, etc.

[0110] The devices, systems, materials, compounds, compositions, articles, and methods described herein can be understood by referring to the above detailed description of specific aspects of the disclosed subject matter. However, it should be understood that the above-described aspects are not limited to specific devices, systems, methods, or specific agents, and therefore may vary. It should also be understood that the terms used herein are for the purpose of describing specific aspects only, and are not intended to be limiting.

[0111] Although several embodiments have been described, it will be understood that various modifications may be made without departing from the scope of the claims herein. Accordingly, other embodiments are within the scope of the following claims. [Explanation of symbols]

[0112] 10 Mastoid bone, bone 25 External auditory canal, external ear 26 levels 30 Tympanic membrane, TM 31 Eardrum perforation, perforation 40 Middle ear, middle ear cavity, middle ear space 42 Eustachian tube 50 Cholesteatoma or soft tissue lesion 60 Traditional simple mastoidectomy 80 Tympanostomy Tube, Tympanostomy Ear Drainage Tube 100 Minimal Mastoidectomy 120 Equipment 200 Tympanic membrane port device, TM port device 202 Lumen 204 distal end section, section 206 middle part, part 208 Proximal end portion, portion, proximal portion 210 TM port or lens assembly, TM port, TM lens assembly 220 Suction devices 300 Injection instruments and instruments 400 Equipment 500 Balloon Catheter Device 520 Balloon 600 Cannula or needle, needle or cannula 1000 Coaxial bipolar diathermy instruments, coaxial diathermy instruments, diathermy probe instruments, one-handed instruments 1010 probe 1020 Distal tip 1022 beams, built-in lighting 1024 Arrow, Suction 1100 Pneumatic Suction Cutter 1110 outer shaft 1120 Inner reciprocating shaft 1900 Rotating Suction End Cutter 1910 outer shaft 1912 Opening 1920 Inner rotating shaft 1920a Inner rotating shaft

Claims

1. 1. A device for treating cholesteatoma at the level of the ossicles in the middle ear, comprising: a shaft configured to be advanced transtympanically through a 0.5 mm to 1.0 mm diameter port lumen so that a distal tip of the instrument contacts the cholesteatoma at the level of the ossicles through the tympanic membrane; a distal tip of the instrument that injects a therapeutic agent into the cholesteatoma from the distal tip to debulk the cholesteatoma via the transtympanic approach, and applies ultrasonic emulsification to the cholesteatoma from the distal tip of the instrument to emulsify at least a portion of the cholesteatoma; An apparatus comprising:

2. 10. The device of claim 1, wherein the shaft passes through a perforation in the tympanic membrane located between the ear canal and the middle ear.

3. The instrument of claim 2 , further comprising a port device disposed within the fenestrations, the shaft extending through a lumen of the port device while the port device is within the fenestrations.

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