Comment on: “Outcomes of Drill Canalplasty in Exostoses and Osteoma

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To the Editor: I would like to congratulate Grinblat et al. (1) on their recent publication detailing their results and perspectives on using a postauricular drilling technique to remove ear canal exostoses. This can certainly be challenging surgery in severely narrowed ear canals, and the postauricular approach employing drilling is familiar to otologists and uses readily available instrumentation.
One perspective that is lacking in Grinblat's paper, is that of the patient. For some patients, a decline in high frequency hearing due to the noise of drilling is undesirable. Similarly, for some patients, the morbidity of a postauricular approach is something they wish to avoid. Over the past 18 years, I have performed ear canal enlargement with a transcanal approach employing 1 mm straight and curved osteotomes; a variety of bone curettes; and minimal use of drilling (for a few minutes on the anterior wall in approximately 5% of patients) on 1,999 ear canals of 1,121 individuals (including 18 physicians, two of whom were otolaryngologists). The severity of ear canal closure in these patients (82% grade V) is greater than that in Grinblat's study (30% grade V). The patients have come from 26 states in the United States and 14 countries outside the United States. Approximately, 10% of these patients have had previous drilling via a postauricular approach; had recurrence of symptomatic exostoses and sought a different operation for their second surgery. A typical patient perspective is summarized in this unsolicited comment: “Dr. Hetzler's surgical method for treating surfers ear should be the new standard. I’ve had the ‘incision behind the ear + power drill’ method on my left ear (1990's), and Dr. Hetzler's technique on my right ear (2015). The healing and recovery time was only three weeks and nearly pain free.” (2)
I had previously used a predominantly drilling technique, and in comparing the use of drilling and osteotomes for this condition, my perspective is that with proper instrumentation and technique, the use of 1 mm osteotomes transcanal more readily preserves the ear canal skin and its blood supply; the 1 mm osteotome is well-suited to cleaving the bone growths along natural cleavage planes; and the noise associated with using osteotomes is negligible. Some of the disadvantages of a transcanal osteotome technique are that most otologists do not have the proper instrumentation or experience in using the instrumentation.
A relevant commentary on this topic was published in 1889: “Much controversy has arisen as to the best method of operating on bony growths in the ear. Disputants should remember that the very greatest variety exists in the size, position, shape, character, and complications of such growths; and those who advocate only one method of operation are most probably those who have had but limited experience of the others.”(3)
Surgeons should employ techniques with which they can get the best results and give patients their desired outcome. Employing a variety of devices gives the surgeon and the patient the best opportunity to achieve these goals.

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