OBJECTIVE:To evaluate the surgical accuracy and intracochlear positioning of robot-assisted insertion of slim modiolar cochlear implant electrode arrays (CI632) using the RobOtol system in human cadaveric temporal bones. METHODS:A total of 14 fresh-frozen adult cadaveric temporal bones underwent cochlear implantation using RobOtol robot-assistance. Standard mastoidectomy, posterior tympanotomy, and round window exposure were performed. CI632 electrode arrays were robotically inserted at a speed of 0.1 mm/s. Postoperative micro-computed tomography (micro-CT) was performed to assess electrode scalar position, angular insertion depth, modiolar proximity (intracochlear position index), and frequency-to-place mismatch. RESULTS:Robot-assisted insertion of all 22 electrodes was successfully achieved in 14 specimens. Micro-CT analysis confirmed scala tympani placement without evidence of translocation. A total of 13 arrays demonstrated correct perimodiolar positioning, while one was misplaced along the lateral wall. Mean insertion angle of the 13 correctly placed arrays was 406° ± 25° (351°-441°), and mean intracochlear position index was 0.5 ± 0.05. One array (7%) was mispositioned with lateral wall placement, which occurred in a cochlea with a large cochlear duct length (36.4 mm) and a wide basal turn at 90° (4.6 mm). Frequency-to-place mismatch varied across specimens, with a mismatch of 2637 ± 663 Hz (1973-4077 Hz) for the 8th electrode, and 1246 ± 317 Hz (899-1948 Hz) for the 16th electrode, corresponding to approximately one octave. CONCLUSION:Robot-assisted insertion of slim modiolar electrode arrays was feasible and reproducible in human cadaveric temporal bones. One case of mispositioned array occurred in a cochlea with large dimensions, underscoring the importance of preoperative anatomical assessment. LEVEL OF EVIDENCE:N/A.

Objectives:To reduce operator-dependent variability and improve surgical precision, robot-assisted piston prosthesis placement and crimping during otosclerosis surgery may represent a promising approach. However, dedicated microsurgical forceps for this application are not yet available in clinical practice. This study aimed to assess the feasibility and precision of piston prosthesis placement and crimping, comparing manual and robot-assisted techniques. Methods:A 3D-printed temporal bone model was modified to measure forces applied to the incus. Robot-assisted manipulation was performed using a robotic arm coupled with custom-designed microforceps. Five otologists performed two tasks (piston placement and crimping) under three conditions: (1) manual under visual control, (2) robot-assisted, both applied to placement and crimping, and (3) manual without visual feedback, applied to crimping only. This resulted in five procedures, each repeated three times (n = 15). Maximal force (N) and torque (N.mm) were recorded and compared using Mann-Whitney and Kruskal-Wallis tests. Results:Robot-assisted piston placement resulted in lower maximal torque compared with the manual technique (4.2 ± 3.96 vs. 7.5 ± 4.73 N.mm, p = 0.037), with no difference in maximal force. During crimping, robot-assisted manipulation generated lower maximal force (0.15 ± 0.09 vs. 0.27 ± 0.09 N, p = 0.0126) and lower maximal torque (6.1 ± 3.41 vs. 11.5 ± 3.09 N.mm, p = 0.004) than manual crimping. No difference was observed between manual crimping performed with and without visual control. Procedure duration was longer with robot-assisted manipulation for both placement and crimping (all p < 0.0001). Conclusion:Robot-assisted piston prosthesis placement and crimping were feasible and were associated with reduced mechanical loads applied to the incus. Level of Evidence:5.

Objectives:Rodents are used in most otological research studies and the choice of the most appropriate animal model may be crucial in studies of ear diseases and in the development of effective treatments. Here, we used micro-CT to compare temporal bone anatomy between four rodent model animals (guinea pigs, gerbils, rats, and mice) and humans, aiming to better characterize the anatomy of the inner and middle ear, and facial nerve to support informed animal model selection in otologic research. Methods:We generated three-dimensional reconstructions and measured the various middle (tympanic membrane, ossicular chain, and facial nerve) and inner (cochlea, vestibular labyrinth) ear structures. Results:Each structure of the middle or inner ear of each rodent was described and measured. Conclusion:This micro-CT analysis of rodents can guide researchers in their choice of the most suitable middle or inner ear models based on the specific anatomic area of interest. Our findings highlight the strengths and limitations of each species, providing essential insight that could enhance the precision and applicability of otological studies. Level of Evidence:4.

OBJECTIVE:The study aimed to describe the auditory phenotype of patients with bilateral enlarged vestibular aqueduct, including benefits of cochlear implantation, and to look for genotype-phenotype correlation. STUDY DESIGN:Retrospective single-center study. SETTING:Tertiary adult reference center. METHODS:Fifty-eight patients were included. Evolution of pure tone and speech audiometry was analyzed. Cochlear size, vestibular aqueduct width, and endolymphatic duct and sac volume were assessed on both computed tomography scan and magnetic resonance imaging. Genetic explorations were documented, and genotype-phenotype correlations were explored. Outcomes after cochlear implant (CI) were analyzed. RESULTS:Hearing loss was diagnosed at 4 ± 4.0 years, being initially severe-to-profound in 74% of the ears. Sudden sensorineural hearing loss concerned 54% of patients. Both vestibular aqueduct and endolymphatic sac showed symmetric measurements (P < .001). Patients with SLC26A4 biallelic alterations (n = 22) had more associated thyroid disorders (14/22 vs 3/31, P < .001), earlier (2 ± 1.6 years old [yo] vs 5 ± 4.5 yo, P < .001) and lower age-adjusted pure-tone average (P < .001, two-way analysis of variance), and greater endolymphatic sac volume (369 ± 118.1 mm3 vs 194 ± 208.7 mm3, P = .042), compared with patients with unconclusive genetic results. Consequently, more patients with SLC26A4 biallelic alterations received a CI (19/22 vs 17/31, P = .015) and at an earlier age (18 ± 12.5 yo vs 34 ± 18.9 yo, P = .009). Finally, 12 months after cochlear implantation, speech intelligibility for words improved from 23% ± 27.6% to 61% ± 34.7% in silence (P = .0012), and from 30% ± 31.3% to 87% ± 10.6% in noisy conditions. CONCLUSION:The auditory phenotype of patients with bilateral enlarged vestibular aqueduct is variable but seems to be more severe in case of biallelic alterations of SLC26A4. However, cochlear implantation benefits to these patients, regardless of genotype.

OBJECTIVE:To evaluate the functional results of robot-assisted laser guidance in otosclerosis surgery. STUDY DESIGN:Retrospective case-control study. SETTING:Otology/neurotology tertiary referral clinic. PATIENTS:Patients operated for primary microscopic stapes surgery performed by a single surgeon from August 2018 to October 2022 using the robot-assistance or the manual technique. INTERVENTIONS:Primary otosclerosis surgeries with robot-assistance or the conventional manual technique. MAIN OUTCOME MEASURES:Evaluation of the audiologic outcome of air conduction, bone conduction, air-bone gap and speech recognition threshold at 3 months and 1 year postoperative. Intraoperative observations, prosthesis choice, and operation duration were collected. RESULTS:A total of 74 patients were operated on for otosclerosis, of which 45 patients were operated on with robot-assistance, and 46 with the conventional manual technique. A reduction of laser shots (2 vs. 3) was necessary to perform footplate fenestration in the robot-assisted group ( P <0.02). Both groups had similar audiometric outcomes. In the robot-assisted group, successful closure of an air-bone gap of <15 dB was achieved in 94% of patients at 3 months, and in 100% at 1 year, compared with 92% at 3 months ( P >0.99) and 97% at 1 year ( P <0.48) in the manual group. Air-bone gap closure of <10 dB was attained in 86% and 82% at 3 months ( P <0.76) and 97% and 93% at 12 months ( P <0.61) in the robot-assisted and manual groups, respectively. Both groups improved postoperatively in air conduction thresholds and air-bone gaps while maintaining a stable bone conduction. CONCLUSION:This study reports the use of robot assistance as a laser holder for otosclerosis surgery, which indicates similar audiologic outcomes and no major complications. Robot-assisted otosclerosis surgery is a reliable and safe technique.

Cochlear implant (CI) effectiveness in asymmetric hearing loss (AHL) is well established, but CI use over time and daily usage are rarely monitored by health care systems. Continued use of the CI after the first year could be considered an indirect indicator of subjective benefit. The objective of this study was to evaluate CI use with a follow-up period of 5 years. Sixty-four patients were included in this retrospective study. AHL candidates included patients with an aided speech perception score (SPS) < 50

OBJECTIVE:To evaluate long-term hearing outcomes following cochlear implantation in patients with neurofibromatosis type 2 and ipsilateral vestibular schwannoma. STUDY DESIGN:Retrospective study. SETTING:Tertiary general hospital. METHODS:Twenty-two patients undergoing cochlear implantation between 2004 and 2018 with at least 1 year of follow-up were included. Patients were categorized as "users" or "nonusers" of their cochlear implant (CI). For users, speech perception (disyllabic words) without lip-reading was assessed in quiet conditions 1-year postimplantation, and annually thereafter. CI users were classified into 2 groups on the basis of speech intelligibility (≥40% or <40%). Demographic data, treatment options, and tumor size were also recorded. RESULTS:One year after implantation, 16 (73%) patients used their CI daily. Twelve of these patients had a speech intelligibility ≥40% (mean: 74 ± 21.9%). Three had a Koos stage IV tumor. At the last visit (mean duration of follow-up: 6 ± 5 years), 12 of these 16 patients were still using their implant daily, and 6 had a speech intelligibility ≥40%. No predictive factors for good performance at 1 year or performance stability were identified. CONCLUSION:Neurofibromatosis type 2 is a complex disease profoundly affecting patient quality of life, and cochlear implantation should always be considered on a case-by-case basis. In some individuals, cochlear implantation can provide good speech intelligibility for extended periods, even posttreatment or in cases of large tumors.

OBJECTIVE:To assess trauma patterns associated with the insertion of lateral wall electrode arrays. The study focused on 3 categories-scala tympani (ST), intermediate, and scala vestibuli (SV)-to identify traumatic patterns and contributing factors. STUDY DESIGN:Retrospective study. SETTING:Data from 106 cochlear implant recipients at a tertiary otologic center. METHODS:Demographic and surgical data were collected from recipients who underwent cochlear implantation manually and with RobOtol®. Measurements included cochlear dimensions, angular depth of insertion, and position of the first electrode. Three-dimensional reconstructions were used to analyze the electrode array location relative to the basilar membrane, categorized into ST, intermediate, and SV electrodes. Nontraumatic insertion was defined as all electrodes in the ST, while traumatic insertions had 1 or more electrodes in intermediate or SV locations. RESULTS:Out of 106 cases, 44% had nontraumatic and 56% had traumatic insertions. Demographic and surgical characteristics showed no association with traumatic insertions. A deeper position of the first electrode, relative to the round window, was associated with traumatic insertions (P = .03). Three trauma patterns were observed: distal (facing the apical electrodes), proximal (facing the middle electrodes around 180°), and distal/proximal. CONCLUSION:This study considers the intermediate position which could be associated with basilar membrane lesions. Risk zones for intracochlear trauma with lateral wall arrays were identified distally and proximally. Traumatic insertions were independently linked to deeper array placement. Future studies should explore whether gentler insertion, without insisting on further electrode array insertion depth, could reduce the trauma during cochlear implantation.

Introduction: Auditory performance in noise of cochlear implant recipients can be assessed with the adaptive Matrix test (MT); however, when the speech-to-noise ratio (SNR) exceeds 15 dB, the background noise has any negative impact on the speech recognition. Here, we aim to evaluate the predictive power of aided pure-tone audiometry and speech recognition in quiet and establish cut-off values for both tests that indicate whether auditory performance in noise can be assessed using the Matrix sentence test in a diffuse noise environment. Methods: Here, we assessed the power of pure-tone audiometry and speech recognition in quiet to predict the response to the MT. Ninety-eight cochlear implant recipients were assessed using different sound processors from Advanced Bionics (n = 56) and CochlearTM (n = 42). Auditory tests were performed at least 1 year after cochlear implantation or upgrading the sound processor to ensure the best benefit of the implant. Auditory assessment of the implanted ear in free-field conditions included: pure-tone average (PTA), speech discrimination score (SDS) in quiet at 65 dB, and speech recognition threshold (SRT) in noise that is the SNR at which the patient can correctly recognize 50% of the words using the MT in a diffuse sound field. Results: The SRT in noise was determined in 60 patients (61%) and undetermined in 38 (39%) using the MT. When cut-off values for PTA <36 dB and SDS >41% were used separately, they were able to predict a positive response to the MT in 83% of recipients; using both cut-off values together, the predictive value reached 92%. Discussion: As the pure-tone audiometry is standardized universally and the speech recognition in quiet could vary depending on the language used; we propose that the MT should be performed in recipients with PTA <36 dB, and in recipients with PTA >36 dB, a list of Matrix sentences at a fixed SNR should be presented to determine the percentage of words understood. This approach should enable clinicians to obtain information about auditory performance in noise whenever possible.

This retrospective monocentric study aimed to evaluate long-term auditory brainstem implant (ABI) function in patients with neurofibromatosis type 2, and to investigate the prognostic factors for ABI use. Between 1997 and 2022, 27 patients with at least five years of follow-up underwent implantation with 32 ABIs. At 1- and 5-years post-implantation and at last follow-up, ABIs were classified as used or non-used and the size of the ipsilateral tumor was recorded. For patients who used their ABIs, we assessed speech perception (disyllabic words, MBAA sentences) in quiet conditions with the ABI only, by lip-reading (LR), and with a combination of the two (ABI + LR). Hearing improvement was calculated as Δ ABI = (ABI + LR)–LR scores. Predictive factors for ABI use were analyzed. One year post-implantation, 74 Δ ABI revealed a hearing improvement of 32–41

In cochlear implantation, a scala vestibuli (SV) insertion of an electrode array is a rare occurrence and is reported to be linked to poor hearing outcomes. Using the same electrode array, the auditory performance of patients with a complete SV location was compared with that of patients having a complete scala tympani (ST) location 1 year after implantation. Thirty-three patients were included in this retrospective case–control study (SV, n = 12; ST, n = 21). The matching criteria were electrode array type, age at implantation, and duration of severe or profound deafness. The array location was analyzed using 3D reconstruction of postoperative CT scans. Postoperative audiological evaluation of the implanted ear was performed using pure-tone audiometry, speech recognition of monosyllabic words in quiet, and words and sentences in noise. On the preoperative CT scan, six patients in the SV group presented with both round window (RW) and ST ossification, three with RW ossification alone, and three with no RW ossification. Auditory performance did not differ between SV and ST groups 1 year after cochlear implantation. Speech recognition of words was 49 ± 7.6

Mixtures of hyaluronic acid (HA, in the semi-dilute entangled regime) with liposomes (high lipid concentration) exhibit a great interest in drug delivery. Considering the difference of microstructures when varying the liposome surface, we aimed to determine if liposome characteristics (surface and size) also influenced their release from these hybrid systems and to explore the mechanisms involved. Small-angle neutron scattering, cryogenic electron microscopy, zetametry, and dynamic light scattering were used to characterize liposomes. The implemented Transwell® model (two compartments separated by a polycarbonate membrane) showed that both size and surface governed liposome release. At 150 nm, anionic liposomes with or without poly(ethylene glycol) chains (PEG) migrated from HA-liposome mixtures, while cationic and neutral ones did not. Furthermore, increasing the size of PEGylated liposomes up to 200 nm or more strongly hindered their migration. Below 200 nm, the smaller the liposome size, the faster the release. Multiple and complex mechanisms (interactions between HA and liposomes, water exchanges, liposome migration, swelling and erosion, and HA reptation) were involved. Their relative importance depended on liposome characteristics. The Transwell® model is a pertinent tool to assess in vitro the release of liposomes over several weeks and discriminate the formulations, depending on the foreseen therapeutic strategy.

Abstract Objectives The objective of this study was to predict occurrence of facial nerve stimulation (FNS) in cochlear implanted patients for far‐advanced otosclerosis (FAO) by correlating preoperative computed tomography (CT)‐scan data to FNS and to evaluate FNS impact on hearing outcomes. Methods Retrospective analysis on 91 ears (76 patients) implanted for FAO. Electrodes were straight (50%) or perimodiolar (50%). Demographic data, extension of otosclerosis on preoperative CT scan, occurrence of FNS, and speech performance were analyzed. Results Prevalence of FNS was 21% (19 ears). FNS appeared during the first month (21%), 1–6 months (26%), 6–12 months (21%), and over 1 year (32%) postimplantation. Cumulative incidence of FNS at 15 years was 33% (95% CI = [14–47%]). Extension of otosclerotic lesions on preimplantation CT‐scan was more severe in FNS ears compared to No‐FNS (p < .05): for Stage III, 13/19 (68%) and 18/72 (25%) ears for FNS and No‐FNS groups, respectively (p < .05). Location of otosclerotic lesions relative to the facial nerve canal was similar whatever the presence or not of FNS. Electrode array had no impact on FNS occurrence. At 1 year post‐implantation, duration of profound hearing loss (≥5 years) and previous stapedotomy were negatively associated with speech performance. FNS did not impact hearing outcomes, despite a lower percentage of activated electrodes (p < .01) in the FNS group. Nevertheless, FNS were associated with a decrease of speech performance both in quiet (p < .001) and in noise (p < .05). Conclusion Cochlear implanted patients for FAO are at greater risk of developing FNS affecting speech performance over time, probably due to a higher percentage of deactivated electrodes. High resolution CT‐scan is an essential tool allowing FNS prediction but not time of onset. Level of evidence 2b, Laryngoscope Investigative Otolaryngology, 2022.

Introduction: Electrode array translocation is an unpredictable event with all types of arrays, even using a teleoperated robot in a clinical scenario. We aimed to compare the intracochlear trauma produced by the HiFocus™ Mid-Scala (MS) electrode array (Advanced Bionics, Valencia, CA, USA) using a teleoperated robot, with an automated robot connected to a navigation system to align the pre-curved tip of the electrode array with the coiling direction of the scala tympani (ST). Methods: Fifteen freshly frozen temporal bones were implanted with the MS array using the RobOtol® (Collin, Bagneux, France). In the first group (n = 10), the robot was teleoperated to insert the electrode array into the basal turn of the ST under stereomicroscopic vision, and then the array was driven by a slow-speed hydraulic insertion technique with an estimated placement of the pre-curved electrode tip. In the second group (n = 5), 3 points were obtained from the preoperative cone-beam computed tomography: the 2 first defining the ST insertion axis of the basal turn and a third one at the center of the ST at 270°. They provided the information to the automated system (RobOtol® connected with a navigation system) to automatically align the electrode array with the ST insertion axis and to aim the pre-curved tip toward the subsequent coiling of the ST. After this, the electrode array was manually advanced. Finally, the cochleae were obtained and fixed in a crystal resin, and the position of each electrode was determined by a micro-grinding technique. Results: In all cases, the electrode array was fully inserted into the cochlea and the depth of insertion was similar using both techniques. With the teleoperated robotic technique, translocations of the array were observed in 7/10 insertions (70%), but neither trauma nor array translocation occurred with automated robotic insertion. Conclusion: We have successfully tested an automated insertion system (robot + navigation) that could accurately align a pre-curved electrode array to the axis of the basal turn of the ST and its subsequent coiling, which reduced intracochlear insertion trauma and translocation.

Cochlear implantation is usually not recommended for prelingual profoundly deaf adults, although some of these patients might benefit from it. This study aims to define the candidates for cochlear implantation in this population. This retrospective study reviewed 34 prelingual profoundly deaf patients who had received a cochlear implant at 32 ± 1.7 years old (16–55), with at least 1 year of follow-up. Speech perception and quality of life were assessed before and 3, 6, and 12 months after cochlear implantation, then every year thereafter. According to the word speech intelligibility in quiet (WSI) 1 year after implantation, two groups were identified: good performer (GP) with WSI ≥ 50% (n = 15), and poor performer (PP) with WSI ≤ 40% (n = 19). At the 1 year mark, mean WSI improved by 28 ± 4.6% (−20–100) (p < 0.0001). In GP, the intelligibility for words and sentences, communication and quality of life scales improved. In PP, the communication scale improved, but not auditory performance or quality of life. GP and PP differed pre-operatively in speech production, communication abilities, and WSI in best-aided conditions. In prelingual profoundly deaf adults, a dramatic auditory performance benefit could be expected after cochlear implantation if the patients have some degree of speech intelligibility in aided conditions and have developed oral communication and speech production.

The scalar position of the electrode array is assumed to be associated with auditory performance after cochlear implantation. We propose a new method that can be routinely applied in clinical practice to assess the position of an electrode array. Ten basilar membrane templates were generated using micro-computed tomography (micro-CT), based on the dimensions of 100 cochleae. Five surgeons were blinded to determine the position of the electrode array in 30 cadaveric cochleae. The procedure consisted of selecting the appropriate template based on cochlear dimensions, merging the electrode array reconstruction with the template using four landmarks, determining the position of the array according to the template position, and comparing the results obtained to histology data. The time taken to analyze each implanted cochlea was approximately 12 min. We found that, according to histology, surgeons were in almost perfect agreement when determining an electrode translocated to the scala vestibuli with the perimodiolar MidScala array (Fleiss' kappa (κ) = 0.82), and in moderate agreement when using the lateral wall EVO array (κ = 0.42). Our data indicate that an adapted basilar membrane template can be used as a rapid and reproducible method to assess the position of the electrode array after cochlear implantation.

Key points: (no abstract required) • Cochlear implant effectiveness in asymmetric hearing loss and single-sided deafness is well established, but rarely covered by health care systems. • Continuation of wearing the implant beyond the first year could be considered as an indirect indicator of subjective benefit. • Percentage of cochlear implant abandon at 5-years post-implantation was very low in patients with asymmetric hearing loss and single-sided deafness. • High education level, low audibility and good unaided speech perceptions scores of the contralateral acoustic-hearing ear were positive prognostic factors of CI use. • The low percentage of non-users is an additional strong argument to recommend cochlear implantation in patients with asymmetric hearing loss and single-sided deafness, on the ear with a profound hearing loss, especially in case of frail contralateral acoustic-hearing ear.

In the last two decades, cochlear implant surgery has evolved into a minimally invasive, hearing preservation surgical technique. The devices used during surgery have benefited from technological advances that have allowed modification and possible improvement of the surgical technique. Robotics has recently gained popularity in otology as an effective tool to overcome the surgeon's limitations such as tremor, drift and accurate force control feedback in laboratory testing. Cochlear implantation benefits from robotic assistance in several steps during the surgical procedure: (i) during the approach to the middle ear by automated mastoidectomy and posterior tympanotomy or through a tunnel from the postauricular skin to the middle ear (i.e. direct cochlear access); (ii) a minimally invasive cochleostomy by a robot-assisted drilling tool; (iii) alignment of the correct insertion axis on the basal cochlear turn; (iv) insertion of the electrode array with a motorized insertion tool. In recent years, the development of bone-attached parallel robots and image-guided surgical robotic systems has allowed the first successful cochlear implantation procedures in patients via a single hole drilled tunnel. Several other robotic systems, new materials, sensing technologies applied to the electrodes, and smart devices have been developed, tested in experimental models and finally some have been used in patients with the aim of reducing trauma in cochleostomy, and permitting slow and more accurate insertion of the electrodes. Despite the promising results in laboratory tests in terms of minimal invasiveness, reduced trauma and better hearing preservation, so far, no clinical benefits on residual hearing preservation or better speech performance have been demonstrated. Before these devices can become the standard approach for cochlear implantation, several points still need to be addressed, primarily cost and duration of the procedure. One can hope that improvement in the cost/benefit ratio will expand the technology to every cochlear implantation procedure. Laboratory research and clinical studies on patients should continue with the aim of making intracochlear implant insertion an atraumatic and reversible gesture for total preservation of the inner ear structure and physiology.

This manuscript summarizes available evidence-based best practices in the development, translation, and cultural adaptation of one type of outcome measure for adults with hearing impairment, patient-reported outcome measures (PROMs). It presents the development of the Cochlear Implant Quality of Life (CIQOL) instruments and the ongoing translation and cultural adaptation of the CIQOL-35 Profile from English to French as case studies and discusses useful lessons for selecting, developing, translating, culturally adapting, and using PROMs. Relevant best practice guides are introduced, described and their steps are illustrated with examples. Future trends in hearing-related PROMs, including computerized adaptive testing, patient-reported experience measures (PREMs), economic evaluation and allocation of scarce resources, and PROMs in low-resource settings, are discussed. The manuscript concludes on the lessons that can be learned from implementation science for the successful and sustainable integration of PROMs in clinical practice.

Background: Endoscopy during middle ear surgery is advantageous for better exploration of middle ear structures. However, using an endoscope has some weaknesses as surgical gestures are performed with one hand. This may trouble surgeons accustomed to using two-handed surgery, and may affect accuracy. A robot-based holder may combine the benefits from endoscopic exposure with a two-handed technique. The purpose of this study was to assess the safety and value of an endoscope held by a teleoperated system.Patients and Methods: A case series of 37 consecutive patients operated using endoscopic exposure with robot-based assistance was analyzed retrospectively. The RobOtol® system (Collin, France) was teleoperated as an endoscope holder in combination with a microscope. The following data were collected: patient characteristics, etiology, procedure type, complications, mean air and bone conduction thresholds, and speech performance at 3 months postoperatively. Patients had type I (myringoplasty), II (partial ossiculoplasty), and III (total ossiculoplasty) tympanoplasties in 15, 14, and 4 cases, respectively. Three patients had partial petrosectomies for cholesteatomas extending to the petrous apex. Finally, one case underwent resection of a tympanic paraganglioma. Ambulatory procedures were performed in 25 of the 37 patients (68%).Results: Complete healing with no perforation of the tympanic membrane was noted postoperatively in all patients. No complications relating to robotic manipulation occurred during surgery or postoperatively. The mean air conduction gain was 3.8 ± 12.6 dB for type I (n = 15), 7.9 ± 11.4 dB for type II (n = 14), and −0.9 ± 10.8 for type III tympanoplasties (n = 4), and the postoperative air-bone conduction gap was 13.8 ± 13.3 dB for type I, 19.7 ± 11.7 dB for type II and 31.6 ± 13.0 dB for type III tympanoplasty. They was no relapse of cholesteatoma or paraganglioma during the short follow-up period (<1 year).Conclusion: This study indicates that robot-assisted endoscopy is a safe and trustworthy tool for several categories of middle ear procedures. It combines the benefits of endoscopic exposure with a two-handed technique in middle ear surgery. It can be used as a standalone tool for pathology limited to the middle ear cleft or in combination with a microscope in lesions extending to the mastoid or petrous apex.