Endoscopic versus microscopic stapedotomy: a comprehensive systematic review and meta-analysis incorporating all comparative evidence.

BACKGROUND: Microscopic stapedotomy (MSS) is the established surgical standard in stapes surgery. Endoscopic stapedotomy (ESS) has recently emerged as an alternative surgical approach, but a comprehensive comparison of its efficacy and safety, including evidence from all study designs, is lacking. This systematic review seeks to evaluate the efficacy and safety of ESS versus MSS. METHODS: We systematically searched four electronic databases until July 2025 to identify relevant studies. We included randomized controlled trials, non-randomized controlled studies, and observational studies comparing ESS versus MSS. The audiological outcomes were air-bone gap (ABG), air, and bone conduction. Other intraoperative and postoperative outcomes included scutum debridement, Chorda tympani nerve (CTN) manipulation, pain, and dysgeusia. A random-effects model was used to pool the risk ratio (RR), mean difference (MD), or standardized mean difference (SMD) with 95% confidence intervals (CI). RESULTS: Thirty-six studies (2208 patients) were included. ESS showed a modest ABG improvement over MSS (MD = -1.30, 95% CI [-2.54, -0.05], p = 0.04), though not consistent across sensitivity and subgroup analyses. Bone conduction (MD = 0.57, 95% CI [-0.44, 1.57], p = 0.27), air conduction (MD = 0.07, 95% CI [-1.61, 1.76], p = 0.93), and operative time (MD = -3.81, 95% CI [-10.68, 3.07], p = 0.28) were comparable between both approaches. ESS significantly reduced scutum debridement (RR = 0.72, 95% CI [0.60, 0.88], p = 0.001), CTN manipulation (RR = 0.42, 95% CI [0.25, 0.71], p = 0.001), and dysgeusia (RR = 0.50, 95% CI [0.36, 0.70], p < 0.001). CONCLUSION: ESS provides comparable hearing outcomes to MSS while reducing chorda tympani nerve manipulation, dysgeusia, and the need for scutum removal. These findings support ESS as a viable alternative to MSS when performed by experienced surgeons.