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Editor

Marcos V. Goycoolea,
M.D., M.S., Ph.D.
Mi nne s o t a Ear, He a d & Ne c k Cl inic
Mi nne a pol i s , Mi nnes ot a
Co-Editors
Michael M. Paparella, M.D.
Mi nne s ot a Ear , Mead & Ne c k Cl i ni c
Mi nnes ot a
Rick L. Nissen, M.D.
Mi nnes ot a Ear , He a d & Ne c k Cl inic
Mi nne a pol i s , Mi nnes ot a
ATLAS OF
Otologic
Surgery
1989
W.B. SAUNDERS COMPANY
Harcourt Brace Jovanovirh, Inc.
Philadrlphia ' l^ondon / Toronto
Montreal ' Svdnev ' Tokyo
s a u n
d e r S
c o mp a n y
. Brace Jovanovich. Inc.
| u . f urt ^ Center
dependence Square Wesl
hiuTdelphia. PA 1910 6
Library of Congress Cataloging-in-Publication Data
Govcool ea, Mar cos V.
Al ias of otol ogic surgery.
Bibl iography: p.
I Ear Sur ger yAl i as es . I. Papar el l a, Mi chael M.
11 Ni ssen, Kick I. . III. Ti t l e. [ DNLM: 1. Ea r -
s ur ger y- al i as es . WV 1 7 G7 2 4 a |
RF295. G6 9 1989 6I 7. 8TO9
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nor: W, II. Saunders Stall
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a s
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^19H9 by W. B. Saunders Company. Copyright under the Uniform Copyright Conven
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'rom the publisher. Made in the United Stales of America Library of
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PURO CHILE ES TU CIELO AZULADO
PURAS BRISAS TE CRUZAN TAMBIN
Y ESE CAMPO DE FLORES BORDADO
ES LA COPIA FELIZ DEL EDEN . . .
A TI. DULCE PATRIA
(from the Chilean national anthem)
Contributors
Gwenn Afton, M. S.
Me di c a l I l l us t r a t or , Mi n n e s o t a Ea r , He a d a nd Ne c k Cl i ni c a nd Be c k Vi s ua l
Co mmu n i c a t i o n s , Mi n n e a p o l i s , Mi n n e s o t a .
Marcos V. Goycoolea, M. D. , M. S. , Ph. D.
Mi n n e s o t a Ea r , He a d a nd Ne c k Cl i ni c . Ot o l o g y Co ns ul t a nt , Ch i l e a n Mi l i t a r y
Ho s pi t a l a nd Audi a Ch i l e , S a nt i a g o , Ch i l e .
Peter Hilger, M. D. , M. S.
As s i s t a nt P r o f e s s o r , D e p a r t me n t o f Ot o l a r y ng o l o g y , Uni v e r s i t y o f Mi n n e s o t a .
S t a f f P h y s i c i a n, S t . Pa ul R a ms e y Me di c a l Ce nt e r , S t . P a ul , Mi n n e s o t a .
Ti mothy K. Jung, M. D. , Ph. D.
As s o c i a t e P r o f e s s o r , Di v i s i o n o f Ot o l a r y ng o l o g y a n d He a d a nd Ne c k S ur g e r y ,
L o ma Li nda Uni v e r s i t y , L o ma Li nda , Ca l i f o r ni a .
Sherry Lamey
He a d t e c h no l o gi s t , Ot o p a t h o l o g y La b o r a t o r y , D e p a r t me n t o f Ot o l a r y ng o l o g y ,
Uni v e r s i t y o f Mi n n e s o t a .
Alan J. Nissen, M. D.
Ca l i f o r ni a Ea r I ns t i t ut e , P a l o Al t o , Ca l i f o r ni a . Cl i ni c a l I ns t r uc t o r , S t a nf o r d
Uni v e r s i t y , P a l o Al t o , Ca l i f o r ni a .
Rick L. Nissen, M. D.
Mi n n e s o t a Ea r , He a d a n d Ne c k Cl i ni c .
Michael M. Paparella, M. D.
Mi n n e s o t a Ea r , He a d a nd Ne c k Cl i ni c . Ch a i r ma n Eme r i t us , Cl i ni c a l P r o f e s s o r ,
a nd Di r e c t o r o f t h e Ot o p a t h o l o g y La b o r a t o r y , D e p a r t me n t o f Ot o l a r y ng o l o g y ,
Uni v e r s i t y o f Mi n n e s o t a .
Donald Robertson, Ph. D.
As s o c i a t e P r o f e s s o r , D e p a r t me n t o f Ot o l a r y n g o l o g y a nd D e p a r t me n t o f Ce l l
Bi o l o gy a nd Ne u r o a n a t o my , Uni v e r s i t y o f Mi n n e s o t a .
Kurt Schellhas, M. D.
Di r e c t o r o f Ne ur o - I ma g i ng , Ce n t e r f or Di a gno s t i c I ma gi ng, S t . Lo ui s P a r k,
Mi n n e s o t a .
V
vi Co nt r i b u t o r s
Ro b e r t S mi t h , M . D .
Ch i e f Re s i de nt , De p a r t me n t o f Ot o l a r y ng o l o g y , Uni v e r s i t y o f Mi n n e s o t a .
Edwa r d W. S z a c h o wi c z , M . D . , P h . D .
As s i s t a nt P r o f e s s o r , De pa r t me nt o f Ot o l a r y ng o l o g y , Uni v e r s i t y o f Mi n n e s o t a .
St a f f P h y s i c i a n, S t . Pa ul R a ms e y Me di c a l Ce nt e r , S t . Pa ul , Mi n n e s o t a .
Motto
Learn to learn from everything you do
and everybody around you.

Key Words
An a t o my
F unc t i o n
P a t h o g e ne s i s
Re s e a r c h
O p e n mi nd
C o mmo n s e n s e
De di c a t i o n
Preface
This book is written primarily for physicians in training (residents). It is
my aim to make it a dialogue with you, the residents, beginning with the
preface itself. The origin of this book goes back to my first year of residency in
Otolaryngology. Although many good texts were available, 1 felt that I needed
a book that went back to basics in clear and understandable language, and that
would provide me with the essential concepts from which to start. It seemed
to me that a complicated organ such as the ear could be made, at least at that
stage, a little simpler (not simple). Over time 1 have been thinking of different
aspects that 1 felt to be important and useful for this purpose, and 1 asked the
different contributors to do the s al * . Accordingly, we have tried to create a
book that emphasi zes the basics, rather than one that shows our methods.
In the same context, this atlas is only intended to complement other texts
on the subject. Because this is primarily a conceptual atlas, we have made no
attempt to provide detailed discussions of evaluations and indications; such
discussions are provided by the works cited in the list of selected references.
This list also includes publications that describe essential concepts of anatomy
and function. Because of the extent of these subjects, the works available
number in the thousands; we apologize to, those authors whose important
publications are not cited owing to lack of space and request their understand-
ing. We are aware that this first edition will need i mprovements. It is our hope
that these will come from your criticisms and suggestions.
There are a number of thoughts and general philosophies that 1 believe
are useful. 1 do not expect you to agree with them but to be exposed to them
and think. Some of them will make sense, some will not. 1 hope that some of
the latter will make sense to you in, time.
The techniques described in "this book are intended to show different
approaches based on the knowledge of anatomy, function, and pathology.
They are oriented more toward a way of thinking than toward a dogma of
doing, in the expectation that the surgeon will think of each surgical procedure
as a distinct and different act. It is my hope that this will allow the surgeon to
vary an approach according to need> habit, or ability at a specific time. 1 believe
that there is no single best technique for otologic surgery; in order to achieve
a safe and efficient result, different surgeons might select different but equally
valid approaches. It is easy to be rigid; it is even successful, on the whole. It is
harder to tailor your approach case by case since this requires an overall
concept. In the long run, however, it is much more rewarding. Research and
knowledge of anatomy and pathogenesis permit proper changes and i mprove-
ments. Ear surgery can be what you want it to be. If it is to be developed into
an art, knowledge, creativity, dynami sm, and an open mind, together with
common sense, are essential. As in any discipline, there are basic principles;
however, they should be regarded not as rigid rules but rather as underlying
philosophies. An essential point to be remembered is that the aim of surgery
is to solve problems. Patients come to you for you to solve their problem, not
for the surgery itself. In the same context, solving a problem does not mean
applying formulas or fitting patients into treatment classifications. Classifica-
xi
XU Preface
tions and formulas are nothing more than common sense put on paperuse
them as a tool, do not be "ruled by them. " This may seem like a subtle concept
but it makes all the difference in the world. The difference between operating
and solving a problem is like the difference between passing a cloth over a
table and cleaning the table.
Anot her important concept implied here is what I call the concept of
"intent." For all actions that are to be translated into an efficient result, there
must be the intention of obtaining such a result. This involves the rational use
of your senses. When you look through the operating microscope you must
s e e , observe, analyze, and use the information obtained. This is quite different
from "glancing." You must know what you are looking at (based on anatomy)
and the most likely possibilities and alternatives that can be found (based on
pathogenesis).
It is also essential to understand that surgery is in the mind and the heart
and not primarily in the hand. Good hands are important, but they are not
enough. A mechanical task can be performed brilliantly by a moron if it is done
over and over again in the same fashion. The art of surgery lies as much in the
choices as in the act itself, and also in the postoperative care. The medical act
begins with the first clinical visit and ends when the problem is solved.
It is always tempting to simplify our lives with what is "usual" and
"customary. " If you are in pursuit of excellence, avoid this temptation. A
common attitude of residents (we have all been residents and I have not
forgotten the experience) is to proceed as the "books say" or the "journal
says. " Books and journals (including this one) do not say anything; they
present what different authors believe. Although important and valuable, this
information should be treated as a reference, not as dogma.
On patient evaluation: Despite the fact that the amount of information
available and the precision of laboratory studies have had a great impact on
today's medicine, the essential process of evaluation remains unchanged.
Regardless of the facilities available, the patient's history and examination are
as critical as ever. Provided that they are done properly, a diagnosis is reached
most of the time based on history and examination alone. For children, the
parents (usually the mother) are crucial in providing information. Regardless
of a mother's background, she is the one who spent the night with the sick
child and provided food, clothing, cleansing, and so on. The mother will not
tell you what to diagnose and do, but she will provide important clues for the
diagnosis, and at times for treatment. Again, our role is to listen respectfully
and learn; then, using our knowledge, diagnose and if possible tench. Labora-
tory studies confirm impressions, provide documented objective evidence, and
rule out or detect problems or lesions not detectable otherwise. Much can be
said about this; suffice it to mention that laboratory studies are ordered with
specific questions in mind, and should not be ordered if the results are not
oriented toward an action to be taken.
On the procedure of choice: Apart from strict physiopathology, there are
other factors to consider in deciding what benefits an individual most. What is
good for some may not be good for others. A procedure that requires frequent
checkups might not benefit somebody who cannot be checked periodically.
People and ci rcumstances vary and so should your solutions. Although it is
our duty to change attitudes for the better, it is common sense to accept that
some things cannot be changed.
On the risks of surgery: it is important to reiterate that it is the patient
who takes the risk, not the surgeon. How warranted a specific risk is will
depend on the patient's situation and needs, and calls for common sense on
the part of the surgeon. A surgeon should be conservative. Although "every-
body has something that can be operated upon," the surgeon's role is to assess
1
Preface X I I I
if the operation is indicated and really helpful. Conservatism should be a
product both of knowledge and of profound respect for an individual who has
trusted you; it should not come from ignorance or inability to perform what is
needed. As for doing what other surgeons do successfully, again, their
experience should be seen as background and reference and not as dogma. It
is fine to imitate others and this should be done by all means, provided that
what is imitated is understood, agreed upon, and applicable to your patients.
It is important to evaluate and rationalize what the leading surgeons do; behind
each of the true leading surgeons are many hours of study and hard work.
Question positively their methods and rationale. Ask yourself what is intended
by a specific method and why. Is it reasonable? Is it the best way? "Trendy"
procedures and "state of the art" instruments also require thorough knowledge
and understanding. They usually have good reasons behind them; you must
understand and agree with those reasons. If all you need to do is kill a fly, use
a 50 -cent fly swatter; do not buy a $50 , 0 0 0 electronic fly killer because it is
"state of the art. " Trends come and trends go. Use common sense when
investing.
Otologic surgery, like medicine itself, is a never-ending learning process.
You are never too good to learn from everybody else. Seeking advice is a sign
not of weakness but of maturity. Learn to use your senses; observe and listen
to other surgeons and specialists, the operating team, your patients, and others.
Learn positively from those who want to help you and from those who want
to harm or use you. Learn to'Jearn from everything you do and everybody
around you. Each surgical cas< is different. When placing pressure-equalizing
tubes, study the ear canals and their contents, the tympanic membrane, the
middle ear mucosa, characteristics of the effusion, and so on. Relate them to
one another, to the laboratory studies, and to the clinical history. This simple
process will enrich you and you will learn what you never thought you would.
A difficult task is to learn how to accept reality and our lack of true knowledge.
As hard as it is to deal with success, it is harder and demands more stamina
to deal with failure. Complications and unwanted results do happen, even if
you seemingly have done your job properly. Objective self-assessment and
complete revision of the subject should follow every failure, even .if it "was
bound to happen. " You may easily forget 20 0 successful stapedectomies and
never forget one case of hearing loss due to a reparative granuloma. You must
also learn to accept that in many cases in otology, surgery does not turn back
the disease process, and that different individuals have different responses to
similar surgical procedures and different healing capabilities. From this stand-
point alone, the results of tympanoplasty may vary from 6 0 % to 10 0 %. A 6 0 %
success in a population with .poor nutritional background can be better than
90 % in one with optimal nutrition. Percentages are relative; your own and
those of others should be analyzed in their full context. There are many other
points and ideas that 1 would, have liked to discuss here. Some of them are
discussed in the text. U
A few words on the contributors to this atlas:
Gwenn Afton, the illustrator, has an MS in Medical Illustration from the
Medical College of Georgia. I had the privilege of writing the temporal bone
dissection manual that she illustrated as her master's thesis. At the time she
not only performed such dissections herself but requested direct supervision
and explanations. In spite of her being by far the youngest member of this
team, her professionalism, dedication, interest, and talents are what 1 would
have expected from an experienced and famed medical illustrator. I worked
directly with her on each and every drawing (in all chapters) in this atlas.
However, it must be mentioned that the designs for Chapter 1 (Pertinent
Anatomy) were selected by Donald Robertson; for the discussions of neuro-
xiv Preface
4
Preface XV
Donald Robertson has headed the anatomy course for medical and
graduate students in the Department of Cell Biology and Neuroanatomy
(formerly Department of Anat omy), and the yearly course in Head and Neck
Anat omy for otolaryngology residents for 17 years at the University of Minne-
sota. Having been his student both as a resident and as a graduate in anatomy,
1 have appreciated the value of his experience and his teaching. It has been a
privilege for me to have him contribute Chapter 1 (Pertinent Anatomy).
Kurt Schellhas has contributed Chapter 3 (Pertinent Concepts in High
Resolution Temporal Bone Imaging). Kurt went to medical school, did his
residency, and took his neuroradiology fellowship at the University of Minne-
sota. His experience with and clarification of concepts in diagnostic imaging in
otology have been instrumental in this short but conceptual chapter.
Chapter 20 (Plastic Surgery of the Pinna) was written by Ed Szachowicz,
Peter Hilger, and Robert Smith. Ed and Peter trained in Otolaryngology under
Michael Paparella. Ed had postdoctoral training in Plastic Surgery with Drs.
William Wright and Russell Kridel in Houston and Dr. Clyde Litton in
Washi ngton, DC. Peter had his postdoctoral training in Plastic Surgery at
Harvard Medical School and Massachusetts Eye and Ear Infirmary under Dr.
Richard Webster. Robert is currently a Chief Resident at the Department of
Otolaryngology at the University of Minnesota.
Other contributors to this atlas are Dr. Hammed Sajjadi, formerly a Fellow
in our clinic ( 1986 - 1987), who assisted with Chapter 6 (Operating Room
Principles and General Concepts), and Drs. Michael Morris and Richard Fox,
currently otology Fellows, who served as reviewers and critics. Professor A.
Rosales from Santa Cruz, Bolivia, provided me with the di agrams and design
of his consistently successful piston wire prosthesis. David Muchow took the
scanning electron micrograph of the stapes used on the cover, and Jodi Nielsen,
the radiology and vestibular technologist and medical photographer at the
Minnesota Ear, Head and Neck C.inic, took the photographs in Chapter 6 . The
"patients" in this chapter are my children Marcos and Hortensia, and the nurse
is Joanne Eplev, RN, head nurse at our institution. Kay Emery typed and
edited the manuscript and Joyce Hansen assisted in typing. Gail E. Mowen
assisted Alan Nissen with his chapter.
The contributions of grants N. 5P-50 -NS-14538 from the National Institute
of Neurological and Communi ca'i ve Disorders and No. NS-19433-0 4 from the
Deafness Research Foundation, as well as a grant from the 3M Company of
Minnesota, arc acknowledged.
A final note: The opinions in this preface, as well as the selection of the
dedication, key words, and motto, are my own and do not necessarily represent
the opinions and choices of the contributors to this atlas.
Ma r c o s V. G o y c o o l e a , M. D.
otology (in Chapters 5, 17, 18, and 19) by Rick Nissen; and for Chapter 14
(Lasers in Otologic Surgery) by Alan Nissen. We have been asked to lend many
of the illustrations (only those designed by Gwenn and me) to Michael Paparella
for the otology volume of his forthcoming text. 1 have no doubt that with the
appearance of this atlas we are also witnessing the emergence of an artist who
will be a significant contributor to medical illustration in the coming years.
Timothy Jung is my former fellow resident at Minnesota. Tim oriented
his research toward biochemistry of the ear and has remained working in this
area while practicing primarily clinical otolaryngology. He has contributed
directly to the discussions of the Thiersch graft (in Chapter 7) and mastoid
obliteration and surgery for complications of suppurative otitis media (in
Chapter 10 ), and is wholly responsible for Chapter 8 (External Ear Canal
Procedures). His clinical and surgical experience, coupled with his approach
toward ear disease based on anatomy and pathogenesis, made him a natural
contributor to this book.
Sherry Lamey has headed the Otopathology Laboratory at the University
of Minnesota for 20 years. She is, in my opinion, directly responsible for
transforming this laboratory into one of the best, if not the best, of its kind in
the world. Many generations of residents (including mine) and research fellows
have benefited from her knowledge and expertise. The histology and histopa-
thology slides in this atlas, as well as Chapter 4 (Temporal Bone Removal), are
al l products of her work.
In order to include a solid discussion of the use of lasers in otologic
surgery ( Chapter 14), we asked Alan Nissen to be a contributor. Alan trained
at the University of Nebraska and took a postdoctoral fellowship with Dr.
Michael Glasscock in Tennessee. He is currently a member of the California
Ear Institute in Palo Alto, where he has developed expertise in the use of
lasers.
Rick Nissen is a member of our team at the Minnesota Ear Head and
Neck Clinic, where he directs the Neuro-otology division. Rick did his residency
it the University of Nebraska and hail his postdoctoral training in Neuro-
otology at the House Ear Institute in Los Angeles, lie started as a contributor
tn this atlas, but his interest, efficiencv, and understanding of the spirit of the
h ook were such that he also became a co-editor of the chapters dealing wholly
or in part with ncuro-otologv ( Chapters 5, 17, IK. and 19). This section is the
product of his work.
Michael PaparWI.i was Professor and Chairman of flu' Department ol
Olobryngologv at the L'nivcrsitv ot Minnesota for 17 ve.IRS. Under hi s leader-
ship, the department became one ol the primarv otologv centers in the world,
both clinically and in research. Hi s contributions to our specialty in the last
two decades have been among the most significant by any single individual,
a nd his name has a well-deserved place of honor in the historv of otology. In
addition, he had the vision and openness to train specialists from all over the
world. The results of his teachings and philosophies are becoming more evident
every year as his former students gradually reach the highest academi c positions
both in the United States and abroad. After his retirement as active chai rman,
he developed the Minnesota Ear, Head and Neck Clinic. Clinically more active
'han ever, he has continued doing research as Clinical Professor and Director
of t he Otopathology Laboratory at the University of Minnesota. 1 originally
trained with him in Minnesota and have rejoined him at the Minnesota Ear,
He a d and Neck Clinic. When 1 came from Chile to train with him, he opened
' h e doors of the department and of his friendship to me. He has undoubtedly
had a direct influence on my training; at the same time, he has trained many
f the contributors to this work. It was a privilege for me to have Michael as a
c
editor of this atlas.
?
Contents
i
SECTION I Basic Anatomic Concepts 1
CHAPTER 1 Pertinent Anatomy '. 3
Donald Robertson, Ph.D.
CHAPTER 2 Pertinent Histology 23
Marcos V. Goycoohar M.D., M. S. , Ph.D.
CHAPTER 3 Pertinent Concepts in High Resolution Temporal
Bone Imaging 28
Kurt Sdwtlhas, M.D.
SECTION II Temporal Bone Dissection 37
CHAPTER 4 Temporal Bone Removal 39
Marcos V. Goycooiea, M.D., M.S., Ph.D.
Sherry Lamcy
CHAPTER 5 Surgical Procedures 44
Marcos V. Goycoolea, M.D., MS.^Ph.D.
Kick L. Nisscrt, M.D.
SECTION III General Principle<vand Approaches 99
CHAPTER 6 Operating Room Principles and General Concepts 10 1
Marcoa V. Goycootca, M.D.. M.S.? Ph.D
CHAPTER 7 Surgical Approaches to the External Ear Canal and
Middle Ear j 121
Marcos V. Goycaalea, M.D., M.S., Ph.D.
Timothy K. Jung, M.D., Ph.D.
SECTION IV Specific Surgical Approaches 147
CHAPTER 8 External Ear Canal Procedures 149
Timothy K. Jung, M.D., Ph.D.
CHAPTER 9 Congenital Atresia 159
Marcos V. Goycookar M.D., M. S. , Ph.D.
CHAPTER 10 Surgical Procedures in Different Forms of Otitis Media . . . 16 4
Marcos V. Goycoolea, M.D., M.'g., Ph.D.
Timothy K. Jung, M.D., Ph.D.
x v i i
XVlii Contents
K U
> 36 3
SECTION I
Basic Anatomic
Concepts
CHAPTER 11 Exploratory Tympanotomy 210
Marcos V . Guycoofoi, M.D., M. S . , Ph.D.
CHAPTER 12 Tympanoplasty 218
Marcos V. Coycoolea, M.D., M.S., Ph.D.
CHAPTER 13 Surgery for Stapes Fixation 247
Marcos V. Coycoolea, M.D., M.S., Ph.D.
CHAPTER 14 Lasers in Otologic Surgery 272
Alan }. Nissen, M.D.
CHAPTER 15 Surgical Approach for Bone Conduction
Hearing Devices ... 281
Marcos V. Coycoolea, M.D., M.S., Ph.D.
CHAPTER 16 Surgical Approaches for Cochlear Implants 286
Marcos V. Cm/coolea, M.D., M.S., Ph.D.
CHAPTER 17 Surgery for Incapacitating Peripheral Vertigo 297
Marcus V. Coycoolea, M.D.. M.S., Ph.D.
Rick l. Nisse, M.D.
CHAPTER 18 Infratemporal Facial Nerve Surgery 315
Marius V. Govorita. M.D., M.S., Ph.D.
Rnk L. Nissen, M.D.
CHAPTER 19 Tumors of the Middle and Inner Ear 325
Marius V. Coycoolea, M.D.. M.S., Ph.D.
Rick L. Nissen. M.D.
CHAPTER 20 Plastic Surgery of the Pinna 339
Peter Hilter, M.D., M.S.
Mv r f Smith, M. D.
l.tlward W. Szachowicz. M.D.. Ph.D.
SECTION V Selected References 359
CHAPTER 1
Pertinent Anatomy
Fo r des cr i pt i ve pu r po s e s t he e a r i s di vi ded i nt o
t hr e e par t s : (1) t he ext er nal e ar , cons i s t i ng of t he
aur i cl e, t he ext er nal aco us t i c me a t u s , and t he t ym-
pani c me mb r a ne ; ( 2) t he mi d d l e e ar ( t ympani c cavi t y)
a nd t he as s o ci at ed os s i cl es and mus cl es ; a nd ( 3) t he
i nne r e ar , co nt ai ni ng t he o r g ans o f equi l i br at i on a nd
hear i ng .
The External Ear
Bony Features and Relationships
The b o ny c o mp o n e n t s of t he ext er nal e ar ( Fi g. 1
1 ) ar e all par t of t he t e mpo r al bo ne . The y i ncl ude t he
f ol l owi ng:
1. The squamous portion, f o r mi ng a s mal l , s uper i -
or l y l ocat ed par t o f t he bo ny ext er nal aud i t o r y me a t u s
a nd t he ant er o l at er al po r t i o n o f t he mas t o i d pr o c e s s .
Ex t e nd i ng l at eral l y and ant er i or l y f r om t he i nf eri or
par t o f t he s q u a mo u s po r t i o n o f t he t empo r al b o ne
i s t he zygomatic process, whi c h has t hr ee r o o t s . The
anterior root e x t e nd s medi al l y l o b e c o me co nf l uent
wi t h t he ar t i cul ar t uber cl e; t he medial root f o r ms t he
po s t e r i o r wal l of t he mand i b u l ar f ossa; and t he pos-
terior root c u r ve s s l i ght l y d o wn wa r d o nt o t he mas t o i d
pr o c e s s . Thi s r o o t bear s t he s mal l suprameatal spine
( of He nl e ) o n i ts do r s al ext r emi t y. H e nc e , t he u ppe r
po r t i o n of t he ext er nal aco us t i c me a t u s i s l ocat ed
b e t we e n t he mi d d l e and po s t er i o r r o o t s . The cr es t o f
t he po s t er i o r r oot and t he po s t c r o s u pe r i o r po r t i o n o f
t he bo ny me a t u s ar e j oi ned by an i mag i nar y li ne t o
f o r m t he suprameatal triangle, mar ki ng t he si t e of
ac c e s s t o t he a n t r u m o f t he mi ddl e e ar .
2. The tympanic portion, f o r mi ng mo s t of t he b o ny
me at u s . The g r eat es t par t o f t hi s c o mpo ne nt d e ve l o ps
af t er bi r t h, and t he al t er at i on i n f o r m as i t d e ve l o ps
br i ng s abo ut a shi ft i n t he d e pt h of ( he ext er nal
me a t u s as wel l as i n t he o r i ent at i o n o f t he t y mpa ni c
me mb r a n e . In t he ne wb o r n i t i s a sl i ght b o ne ri ng
t hat i s i mper f ect s uper i o r l y. Wi t h s ubs e que nt
g r o wt h, s mal l pr o j ect i o ns of bo ne ar i s i ng f r om i ts
ant e r i o r and po s t er i o r cr ur a e xt e nd i nt o t he l u me n
of t he ri ng, event ual l y f us i ng t o di vi de t he a nnu l u s
i nt o t he s uper i o r l y l o cat ed aco us t i c me at u s pr o pe r
and a s mal l , i nt er i or l y s i t uat ed ape r t u r e . Al t ho u g h
t he l at t er us ual l y cl o s es wi t h c o nt i nu e d d e ve l o pme nt ,
i t ma y on o ccas i o n per s i s t t o f o r m wha t i s d e s i g nat e d
t he foramen o f Huschke. The s uper i o r l y l ocat ed di s co n-
t i nui t y i n t he t y mpa ni c r i ng per s i s t s i nt o adul t life as
t he tympanic notch ( of Ri vi nus ) .
Po s t er i o r l y t he t y mpa ni c ri ng f o r ms , i n c o nj u nc -
t i on wi t h bot h t he s q u a mo u s and pe t r o u s po r t i o ns
of t he mas t o i d pr o c e s s , t he tympanomastoid and petro-
tympanic s ut ur e s ( f r equent l y d e s i g nat e d col l ect i vel y
t he t y mpa no ma s t o i d s ut ur e ) . Ant er i o r l y t he r i ng par -
t i ci pat es i n t he f o r mat i o n of t he squamotympanic a nd
petrotympanic s ut ur e s . It i s i n t he l at t er s u t u r e t hat
t he f o r ame n t r ans mi t t i ng t he c ho r d a t ympani ne r ve
( t he i t er c ho r d a e ant e r i us ) i s f o und. I t s ho ul d be
appr e c i at e d t hat t he t y mpa ni c ri ng, wi t h i ts g r o wt h,
f o r ms a po r t i o n of t he po s t er i o r wal l of t he mand i b -
ul ar f os s a.
3. The petrous portion, f o r mi ng t he t i p and po s t e-
r i or po r t i o n o f t he mas t o i d pr o c e s s .
The Auricle
The aur i cul ar c o mpo ne nt o f t he ext er nal ear c o n-
s i s t s of a s i ngl e car t i l ag i no us pl at e wi t h its c o ve r i ng
s ki n. Thi s car t i l age f r ame wo r k i s r es pons i bl e f or t he
s hape o f t he aur i cl e, a nd d e t e r mi ne s all o f t he var i o us
4 Pertinent Anatomy
FIGURE 1- 1.
Bum l ' o mpnnc nN i>l tin- cvlt-rn.il r.ir
Prominences and depressions seen on the ear, with
he exception of the lobule.
In addition to the features that are superficially
hscemible, the cartilage plate contains other features
hat become evident upon removal of overlying skin,
"riese include the following (Fig. 1-2/1):
1- The spine of the helix, projecting anteriorly from
n e
helix, near the cms .
2 The tail of the helix ( cauda helix), the terminal
Wi o n of the helix, located at the posteroinferior
n a
r gi n of the auricle.
3 The isthmus, the point of continuity between
1 e
auricular and meatal cartilages, located imme-
l a
'ely posterior to the entrance of the external mea-
Js.
I
t
I
+. The lermmai incisure, between the isthmus and
the tragal lamina of the auricular cartilage. Its inferior
extremity is the opening of the external meatus.
Superiorly it is marked by the anterior incisure.
The auricle is attached to the side of the head by
the following features:
1. Its continuity with the cartilaginous portion of the
external acoustic meatus.
2. The skin covering the ear and continuing onto the
skull. The skin of the auricle is tightly bound to
the perichondrium of the lateral aspect of the ear
but is somewhat freer on the medial surface. There
is very little fat in the subcutaneous tissue of the
ear. Except in the tragal and antitragal regions,
the hair of the auricle is rudimentary. Sebaceous
Pertinent Anatomy
F 1 C U R E 1- 2 .
A, Major relationships of the auricular cartilage.
External acoustic meatus.
Mastoid air cells
B
Pertinent Anatomy
gl a nds are present on both surfaces and are par-
t i cul ar l y numerous in the concha and triangular
f os s a.
3 Three extrinsic ligaments. These include:
A. The anterior ligament, extending from the zyg-
oma to the helix and the tragus.
3 . The superior ligament, extending from the su-
perior margin of the bony meatus to the spine
of the helix.
C. The posterior ligament, extending from the mas-
toid process to the concha of the auricle,
i. Muscles, consisting of the following:
A An extrinsic group, formed of three small mus-
cl es (anterior, superior, and posterior) belong-
ing to the facial group of muscles and supplied
by the facial nerve.
B. An intrinsic group of six small muscles, which
are extremely variable in their development
and have no functional significance in humans.
The External Acoustic Meatus
or fissures of Santorini), which assist in imparting a
limited mobility to the auricle.
The major relationships of the meatus are the
following (Fig. 1-2B):
1. Anteriorly and laterally, the parotid gland. The
more medial and anterior relationships include the
mandibular fossa and the condyle of the mandible.
2. Inferiorly, the parotid gland.
3. Superiorly and medially, the epitympanic re-
cess of the middle ear.
4. Posteriorly, the mastoid air cells.
The skin lining the external meatus is continuous
with that of the auricle, and also forms the external
layer of the tympani c membrane. It varies consider-
ably in thickness, being much heavier in the cartilag-
inous portion of the meatus where there is a popu-
lation of large sebaceous glands and numerous fine
hairs. The skin of the bony meatus, which is much
thinner, is firmly bound to the periosteum of the
underlying bone and contains a rather sparse popu-
lation of glands and hair cells, located predominately
on the superoposterior wall.
The external acoustic meatus is a bony-cartilagi-
ous canal extending from the concha of the auricle
5 the tympanic membrane. In its adult configuration
de s c r i be s a slight S-shape, with the lateral cartilag-
lous portion somewhat concave anteriorly and in-
TOirly and the medial bony portion slightly concave
os t er i or l y and superiorly. Owing to the obliquity of
le tympanic membrane, the posterosuperior wall of
le me a t us is slightly shorter than the anteroinferior
all (approximately 25 mm and 31 mm, respectively),
l ightl y more than half of the external meatus is
ntirely bony (medially), with the anterior wall, floor,
nd lower posterior wall formed by the tympanic
ortion of the temporal bone. Its roof and the upper
art of t he posterior wall are formed by the squamous
ortion.
The cartilaginous (lateral) portion of the external
eat us forms a trough-shaped structure that is open
iper ior l y and posteriorly. This canal is completed
' he latter quadrants by the squamous portion of
e temporal bone. In addition to being slightly
>ed, it is somewhat broader in its lateral aspect
"e r e it makes up approximately two thirds of the
rcumference of the meatus. Medially it makes up
"ghl y one third of the meatal wall. At its lateral
tremity the cartilage of the meatus is continuous
' "i that of the auricle through the isthmus; medi-
y. it articulates with the bony portion of the mea-
5
Th e anterior wall is characterized by the presence
h v
" fissures (incisures of the cartilaginous meatus
The Tympanic Membrane
The tympanic membrane (Fig. 1-3/1) is a thin,
elliptically shaped membrane situated between the
medial end of the external meatus and the middle
ear cavity. Its vertical axis measures approximately 9
to 10 mm; its horizontal axis measures approximately
8 to 9 mm. In its final adult position the tympanic
membrane slopes medially from superior to inferior
and from posterior to anterior, so that its external
(meatal) surface faces somewhat inferiorly and an-
terolaterally. In the newborn the membrane is situ-
ated much more horizontally, but gradually shifts to
the adult position with development of the tympanic
portion of the temporal bone.
The major features of the tympanic membrane, as
viewed from the lateral aspect, include the following:
1. The umlw, which is the center of the slight
lateral concavity. It marks the point of attachment of
the tip of the manubri um of the malleus.
2. The malleal stria, extending superiorly and
slightly anteriorly from the umbo. It is formed by the
manubrium of the malleus. The stria and a perpen-
dicular line extending through the umbo divide the
membrane into quadrants ( anterosuperior, anteroin-
ferior, posterosuperior, and posteroinferior).
3. The mallear prominence, marking the attachment
of the lateral process of the malleus to the membrane.
Extending from the promi nence in anteroinferior and
Pertinent Anatomy 7
Mal l ear pr o mi nence
Umbo
Ant . mal l ear t ol d
Para flaccida
Pos t , mal l ear told
F I G U R E 1- 3 .
A, Tympanic membrane. B, Vascular supply of
the tympanic membrane.
posteroinferior directions are, respectively, the ante-
rior and posterior mallear folds.
4. The purs fensa, that portion of the membrane
lying below the mallear promi nence and the mallear
folds and making up the greatest part of the mem-
brane.
5. The purs flaccida, that portion of the membrane
lying above the mallear promi nence and the mallear
folds. It is named for its characteristic laxity.
Structurally, the membrane consists of three layers
approximately 0 .1 mm thick ( combi ned). These in-
clude: ,
1. An outer cutaneous layer of thin skin, which is
conti nuous with the skin of the external meatus.
2. A middle layer of connective tissue consisting of
the following:
A. The radiate fibrous layer, made up of fibers
radiating peripherally from the umbo and ma-
nubrium of the malleus.
B. The circular fibrous layer, made up of concen-
g Pertinent Anatomy
Vascular Supply of the
External Ear
Th e arteries of the external ear originate from
sever al sources. The auricle has an abundant blood
supply, which is derived primarily from the posterior
auricular branch of the external carotid artery and the
auricular rami arising from the superficial temporal
artery. These are shared by the meatus, which also
r ecei ves the deep auricular branch of the maxillary artery.
Thi s artery passes through the parotid gland to enter
either the cartilaginous or bony part of the meatus.
Th e tympanic membrane is supplied on both its
lateral and medial surfaces. Laterally, the deep auric-
ul ar artery forms a small peripheral vascular ring
from which small branches radiate onto the mem-
br ane. Superiorly, a large vessel, the external descend-
ing artery, arises from the vascular ring to descend to
the region of the umbo, with a course more or less
parallel to the manubrium (Fig. 1-3B). Internally, a
second peripheral vascular ring is formed primarily
by the stylomastoid branch of the posterior auricular artery
and t h e anterior tympanic branch of the maxillary artery.
The largest of the vessels arising from this inner
vascular ring is the internal descending artery, which
descends on the inner surface of the membrane in a
course parallel to that of its external counterpart.
The venous channels draining the structures of
Ihe external ear roughly correspond to the arteries of
suppl y. Those draining the auricle and the external
meatus are the anterior auricular tributaries of the
superficial temporal veins and the auricular tributaries
o f
the posterior auricular vein. Drainage of the tym-
P
a r
" c membrane is both external (via vessels com-
m
"nicating with veins of the external meatus) and
"iternal (via branches paralleling the arteries).
innervation of the External Ear
The external ear is a region of transition between
l n
originally overlying the branchial area and the
postbranchial region. For this reason, both the cranial;
nerves supplying the branchial arches (V, VII, IX, I
and X) and the cervical nerves may be represented;
by sensory components. Although there is consid !
erable variation, the approximate sensory DI STRI BUT;
Hon is as follows (Fig. 1-4): . ^
1. The cervical plexus of nerves ( C2- 3 ) , via t he'
great auricular nerve, supplies most of the lateral'
surface of the auricle (except for the upper anterior '.
portion). The lesser occipital nerve from the plexus
supplies much of the medial surface of the auricle.
2. The mandibular division of the trigeminal
nerve, via its auriculotemporal branch, supplies the
upper anterior portion of the auricle, the upper and '
anterior walls of the external meatus, and the upper L
anterior part of the lateral surface of the tympanic
membrane. '
3. The auricular branch of the vagus supplies ap
proximately half of the external meatus and lateral
1
surface of the tympanic membrane. Although this
nerve is typically described as being of vagal origin, t
it should be appreciated that branches of VII and IX.!
may join it and contribute to the sensory innervation ,
of the external ear. It is impossible to differentiate !
between the distribution of the components; clinical I
studies of herpes zoster indicate that all three may,
participate. !
The distribution of nerves supplying the tympani c,!
membrane is very much like that of the arteries '
small, peripheral contributions supplying the mar-,
gins of the membrane while the primary nerves^
descend from the superior aspect of the membrane
and parallel the course of the external descending
artery, tending to lie slightly posterior to the vessel.
The pars tensa of the membrane is not particularly
well supplied with sensory nerves; in contrast, t he
pars flaccida has an extremely rich innervation. >
I
The Middle Ear
Morphology \
i
i
The middle ear, or tympanic cavity, is an irregu-l
larly shaped chamber lying within the temporal bone, i
bounded laterally by the squamous and t ympani c)
portions and medially by the petrous portion. Its-
greatest dimensions are in the anteroposterior and j
vertical planes, which measure approximately 15 mm .
each, while the transverse diameter (between the I
medial and lateral walls) varies with location and i
ranges from 2 to 6 mm. It is not a confined space
but communi cates anteriorly with the nasopharynx i
; Pertinent Anatomy 9
i
FIGURE 1 - 4 .
Innervation of the external ear.
through the auditory tube and posteriorly with the
mastoid antrum and air cells.
The middle ear can be divided into the tympanic
cavity proper, which is that portion situated medial to
the tympanic membrane, and the epitympanic recess,
the upward extension of the tympanic cavity proper
above the level of the tympanic membrane.
The lateral wall ( membranous wall) of the middle
ear is formed for the most part by the tympanic
membrane. Superiorly, within the epitympanic re-
cess this wall is formed by a plate of bone (the
scufwrn) derived from the squamous portion of the
temporal bone. The head of the malletfe and the
body and short process of the incus lie in the epitym-
panic recess.
The roof (tegmental wall) of the middle ear consists
of a thin plate of bone, the legmen tympani, which
separates the epitympanic recess from the cranial
cavity. It is traversed by the petrosquamous suture,
which persists into adult life in approximately 50 %
of the population, and by small foramina that trans-
mit nerves and arteries.
The j'oor (jugular wall) is a very narrow, irregular
surface lying slightly below the level of the meatus,
trically arranged fibers that are most prominent
peripherally, where they thicken to form a
fibrocartilage ring or annulus, attaching the
membrane to the tympanic sulcus of the tem-
poral bone.
3 An inner layer of mucous membrane continuous
with that of the middle ear cavity.
10 Pertinent Anatomy
subiculum and is the site of the cochlear window
( round wi ndow), in which the secondary tympav.c
membrane ( round window membrane) resides, lie
round wi ndow and associated membrane may or
may not be visible, depending upon the size a."id
configuration- of the promontory and subiculum.
3. The tympanic sinus, occupying the midc ie
depression formed by the subiculum and ponticuf is
at the junction of the posterior and medial walls. T> ie
extent of the sinus is variable; it may extend fir
enough into the petrous portion of the temporal
bone to bring it into close relationship to the ampl 1-
lary end of the posterior semicircular canal and tl e
posterior end of the lateral canal.
4. The fossula fenestrae vestibuli (fossa of the oVil
wi ndow or "stapes niche"), lying in the superk r
depression above the ponticulus. It contains the
vestibular (oval) window, whi ch is closed by the
footplate of the stapes and the associated annukr
ligament.
5. A slight bony ridge, the prominence of the latere I
semicircular canal, which lies high on the posterior
aspect of the medial wall in the region of the aditu;.
and marks the anterior end of that component of the
inner ear. ,
6 . The prominence of the facial canal, lying above thr\
posterior edge of the promontory and the oval win-'
dow, immediately below and parallel to the promi-
nence of the lateral semicircular canal. It runs almost
horizontally across the posterior half of the medial
wall, then turns to enter the posterior wall. The facial
nerve courses through this canal.
7. The cocWfnri/orm process, located anterosuper-
iorly on the medial wall. It represents the curved
end of the bony semicanal of the tensor tympani
muscle.
The Ossicles
The ossicles form an articulated bony chain that I
extends across the middle ear and connects the
tympanic membrane with the vestibular window.
This chain acts as a bent lever to convert the vibra-
tions of the tympani c membrane into intensified
thrusts of the stapes against the perilymph.
Developmentally, the ossicles arise from three
different sources. The first branchial arch of the
embryo ( mandibular arch) gives rise to the head of
the malleus and the long and short process of the
incus; the second arch (facial arch), to the long
process of the incus and the stapes. The anterior
process of the malleus develops independent of the
branchial arches as a membranous bone.
and is formed by a plate of bone separating the cavity
f r om the bulb of the internal jugular vein. If the bulb
of the vein is small, the floor may be as much as 8
to 10 mm thick and may contain hyporympani c air
cells. In contrast, a large bulb may cause the floor to
bul ge upward into the middle ear. In such cases the
floor may be imperfect, and the vessel and cavity are
separated only by the mucosa of the middle ear.
The anterior wall (carotid wall) is a very thin, bony
septum separating the middle ear from the carotid
c a na l . Perforations in the plate allow the transmission
of nerves and vessels from the canal to the middle
ear. Above this is the site of the opening of the
semicanal for the tensor tympani muscle, and immedi-
ately inferior to this is the tympanic ostium of the
auditory tube, through which the middle ear com-
municates with the nasopharynx.
The posterior wall (mastoid wall) (Fig. 1-5A) is
somewhat triangular, with the narrowest portion
s i t ua t e d inferiorly where it is related to a number of
tympanic air cells. Superiorly, at the level of the
epitympanic recess, the posterior wall is deficient
and forms the aditus, through which the middle ear
communicates with the mastoid antrum. Salient fea-
tur es of the posterior wall include the following:
1. The pyramidal eminence, located just below the
aditus. At the apex of the eminence is a small
a pe r t ur e that transmits the tendon of the stapedius
muscle.
2. The iter chordae tympani posterior, a small fora-
me n immediately lateral to the pyramidal emi nence.
Through this foramen the chorda tympani nerve
ent er s the middle ear.
3. The posterior sinus, a small fossa just above the
py r a mi da l eminence.
4. The fossa of the incus, situated just above the
pos t e r i or sinus. This marks the point of attachment
of t he posterior ligament of the incus.
Th e medial wall (labyrinthine wall), which sepa-
rates t h e middle ear cavity from the inner ear, is the
mos t complex of the middle ear boundaries. Its major
features are shown in Figure 1-5B:
1. The promontory, a slight elevation formed by
' h e basal turn of the cochlea of the inner ear. Ex-
tending inferiorly and posteriorly from the promon-
tory is a slight ridge, the subioiium. More superiorly,
r unni ng from the posterior aspect of the promontory
t owar d the. pyramidal emi nence, is a second ridge,
' h e ponticulus. The subiculum and, the ponticulus
cr eat e three small depressions on the posterior part
o f
t he medial wall.
2 T h e fossula fenestrae cochleae (cochlear fossa or
round window niche), which is posteroinferior to the
Promontory. The lowest of the three depressions of
l h
e medial wall, it is bounded superiorly by the
Pertinent Anatomy
The major features of the malleus include the
allowing (Fig. U6A):
I A relatively large and heavy head lying within the
epitympanic recess, which bears on its surface a
small facet for articulation with the incus.
> A short, somewhat constricted neck from which
three processes arise, including:
A. The long and prominent manubrium, the largest
of the mallear processes. It is attached to the
tympanic membrane and in turn is the site of
insertion of the tensor tympani muscle.
B. The lateral process, which creates the mallear
prominence of the tympanic membrane.
C. The anterior (long) process, a long and delicate
bony projection in the fetal malleus. In the
adult it is a small bony stump that is the site
of attachment of the anterior ligament of the
malleus.
The malleus is suspended by three small ligaments
Fig 1-6 B), which include the anterior mallear liga-
nent, extending from the anterior process to the
vmpanosquamous fissure; the superior mallear liga-
nent, extending from the top of the head to the roof
jf the epitympanic recess; and the lateral mallear
igament, which runs from the lateral process to the
nargin of the tympani c notch.
Also associated with the malleus is the tensor
ympani muscle. This muscle arises from the cartilag-
nous part of the auditory tube, the adjacent sphe-
loid bone, and the semicanal situated directly above
he osseous portion of the auditory tube. Its tendon
)f insertion passes through the cochleariform proc-
!ss, turns sharply lateral, and inserts on the manu-
>rium of the malleus, close to the neck. The muscle
icts to draw the manubrium medially, tensing the
ympanic membrane, and thus serves a protective
Hinction. The tensor tympani is innervated by a
'ranch of the mandibular division of the trigeminal
l erve.
The mews (Fig. 1-6 C) is characterized by the follow-
ing features:
' A relatively large body that is deeply indented
anteriorly to form an articular facet.
Two bone processes. These include:
A The sliort process, which extends posteriorly
from the body.
B. The slender long process, extending inferiorly
from the body and paralleling the manubrium
of the malleus. On the medial side of the very
distal extremity of the long process is the small
lenticular process, through which the incus ar-
ticulates with the stapes.
Like the malleus, the incus is suspended by small
5'irnents (Fig. I - 6 D) . These are the posterior ligament,
"
K
h acts to hold the short process in the fossa of
the incus, and the superior ligament, which extends '<
from the body to the roof of the epitympanic recess.';
The stapes (Fig. l - 6 ) consists of the following:
1. A small, cylindrical head, which articulates with
the lenticular process of the incusT *
2. Two crura (anterior and posterior), which ex-
tend from the head. The anterior cms is somewhat
shorter and straighter than the posterior.
3. A thin base (footplate), a flattened plate of bone
1
.
attached on its end to the distal extremities of the-
crura. It fits into the vestibular wi ndow and, like thatt
structure, has a straight inferior border and a curved^
superior border.
The ligamentous support of the stapes is through;
the elastic annular ligament, which attaches to the)
margins of the footplate and the vestibular wi ndow
and allows movement of the stapes. Such movement
is greatest at the anterior end and upper border of
the footplate and very slight posteroinferiorly. It has
been stated that loud tones change the normal pat-
tern of movement to a rocking motion; this would
result in a net decrease in the displacement of peri-
lymph, thereby protecting the inner ear. This change
presumably is brought about by contraction of the
stapedius muscle (Fig. 1-6 F), which inserts onto the
posterior crus. As mentioned above, this muscle
serves a protective function by preventing excessive
excursion of the footplate; it does not move the
ossicle unless the ossicular chain is broken. It is
innervated by a branch of the seventh nerve.
The joints of the ossicular chain are true synovial
(diarthrodial) joints with characteristic articular cap-
sules. There are two such joints within the chain.
The first is the incudomalleal, between the head of the
malleus and the body of the incus. This is a relatively
lax joint that allows the movement of the incus to
lag behind that of the malleus; as a result, the
amplitude of the movement of the bony process of
the incus is less than that of the manubrium. The
second joint is the incudostapedial, between the lentic-
ular process of the incus and the head of the stapes.
The Auditory (Pharyngotympanic
or Eustachian) Tube
The auditory tube extends from its tympanic os-
tium within the anterior wall of the middle ear cavity
to its pharyngeal ostium within the nasopharynx.
The latter is situated just posterior to the dorsal end
of the inferior nasal concha. In the adult the tube is
between 30 and 40 mm in length, and has a slight
S-shaped configuration as it passes obliquely down-
14 Pertinent Anatomy
wa r d, medial, and anterior from the middle ear to
t he pharynx. The tympani c ostium is roughly 25 mm
higher than the pharyngeal ostium in the adult.
There are some basic and significant morphologic
differences between the auditory tube of the child
a nd that of the adult; in the child the tube is shorter
a nd relatively wider and more horizontally situated.
Structurally, the auditory tube consists of both
cartilaginous and bony components. The bony por-
tion makes up approximately two thirds of the tube;
jt is widest at the tympanic orifice and gradually
narrows throughout its length, with its anterior ex-
tremity ( the isthmus) the most constricted portion of
t he entire tube. In its course the bony tube is lateral
to the carotid canal, superior to the jugular fossa.
The cartilaginous portion of the tube extends from
t he isthumus to the nasopharynx. It is not totally
cartilaginous, however; its lower lateral and inferior
wal l s consist of fibrous connective tissue overlying
t he tensor and levator veli palatini muscles.
The lumen of the auditory tube, in the resting
state, is a closed, slitlike cavity. The pharyngeal end
of the tube strongly resists passage of air from the
pharynx to the middle ear. Passage from the tym-
panic cavity to the pharynx is much easier.
The Mucosal Lining of the
Middle Ear
The tympanic cavity is lined throughout hv a thin,
transparent, vascular membrane that is continuous
wi t h that of the auditory tube anteriorlv and the
tympanic antrum and mastoid cells posteriorly. The
membrane is tightly bound to the periosteum and
a l s o invests the ossicles and their associated liga-
ments. In reflecting Irom the walls ol the cavitv to
the ossicles and their ligaments, the mucous lining
forms various folds and pouches; the most important
of these are the superior vouch (Prussak's pouch),
situated medial to the pars flaccida of the tympanic
membrane, and the anterior and posterior vouches (of
Troltsch), which are related to the anterior and pos-
terior mallear ligaments respectively.
Vascular Elements of the
Middle Ear
The middle ear receives blood via a number of
small arteries (Fig. 1- 7, 4, 6 ), which with one excep-
tion are derived from the external carotid c its
branches. They include;
1. The anterior tympanic, a branch of the maxillary
artery. It is distributed to the anterior part oi the
cavity, including the medial surface of the tympanic
membrane, and enters the middle ear by parsing
through the petrotympanic fissure.
2. The stylomastoid branch of either the posterior
auricular or occipital artery. This artery ent ers the
facial canal and gives rise to the posterior lyn panic
artery, which then enters the middle ear in corroany
with the chorda tympani nerve.
3. The inferior tympanic artery, derived frorii the
ascending pharyngeal branch of the external carotid.
It accompani es the tympanic branch of nerv? IX
through the tympani c canaliculus to gain the middle
ear cavity.
4. The superficial petrosal and superior tympanic^ ar-
teries, which are both branches of the middle mr nin-
geal artery. The former runs through the facial canal
for a short distance, then pierces the tegmen tym, >ani
to enter the middle ear; the latter enters through the
petrosquamous fissure.
5. The atroficutympitmc arteries arise from the i t t er-
nal carotid as it passes through the carotid canal; and
enter the middle ear by passing through the thin
bony lamina separating the carotid canal from the
middle ear.
The veins of the middle ear parallel the arteries. TUey
are tributary to the superior petrosal dural sinus me t
the pterygoid plexus of veins.
Nerves of the Middle Ear \\
( R R . U
The major nerve of the middle ear is the lumpttmc
1'iathh vt the gU^>ophan,nytvl iicnr (Jarobson's nerve}.
Arising (rom the inferior ganglion of the parent
trunk, the tvnipanic nerve enters the tvmpanic catn-
aliculus through a small foramen located on the crest
of the thin plate of bone separating the juguhr
foramen and the external orifice of the carotid cam I.
Once in the middle ear, the nerve forms the tympanic
plexus within the mucosa overlying the promontor /.
There are two modalities represented in the tympanic
nerve/plexus. The greatest portion of the fibers a e
sensory; these are distributed to the mucosa of t i e
middle ear, the mastoid air cells, and the audito'y
tube. The remaining fibers are parasympathetic and
have no function in the middle ear. Instead, they
emerge from the upper border of the plexus to pierce
the tegmen tympani and run forward on the floor of
Pertinent Anatomy 15
FIGURE 1-7
A-B, Arteries of the middle ear.
Sup. tympanic Petrosal
\d Pertinent Anatomy
Greater petrosal Geniculate ganglion
FIGURE 1-8.
Nerves of the middle ear.
Caroticotympanic
the middle cranial fossa as the lesser petrosal nerve;
ultimately they leave the skull to run with the auric-
ulotemporal branch of V3 and supplv the parotid
gl and.
1 he middle ear receives sympathetic fibers derived
from the internal carotid plexus. These fibers, which
e
nt e r the middle ear along with the caroticotympanic
ar t er i es, are primarily associated with the vessels of
we cavity and have a vasoconstrictive effect.
The chorda tympani branch of the facial nerve enters
he middle ear through the iter chordae posterius.
Passes forward and down between the manubrium
' *e malleus and the long process of the incus,
nen leaves the cavity by passing through the petro-
tympanic suture. The chorda tympani has no func-
n in the middle ear. It contains both parasympa-
J l i c fibers supplying the submandibular and
' "lingual glands and taste fibers for the anterior
0
th. rds of the tongue. After leaving the middle
ear it joins the lingual branch of V3 to be distributed
with that nerve.
Although they do not enter the middle ear, the
nerves to the muscles associated with the ossicles
must be mentioned since they are vital to normal
function. The nerve to the stapedius muscle is a
branch of the facial nerve, and arises from the parent
trunk as it descends through the vertical portion of
the osseous facial canal. The nerve to the tensor
tympani is a branch of the mandibular division of
the trigeminal nerve.
Pneumatization of the
Temporal Bone
The temporal bone exhibits varying degrees of
pneumatization. Because of the intimate relationship
of the middle ear to these areas, a basic appreciation
of the location and extent of pneumatized areas is
desirable.
Since the mastoid process develops from both
petrous and squamous portions of the temporal
bone, there is a sutural line between the two com-
ponents that normally is obliterated with growth.
Occasionally, however, a heavy plate of bone persists
between the two portions, forming what has been
designated [Corner's septum or the "false bottom."
The existence of this septum can cause confusion in
surgical approaches through the mastoid process.
The mastoid process is rather consistently pneu-
matized ( 80 %), the process usually being completed
by the third or fourth year. There is, however,
considerable variation both in its extent and in the
arrangement of the air cells. Because of this variation,
several types are described, including the pneuma-
tized, in which the entire process is occupied by air
cells; the diploic, in which the process is occupied
by bpne marrow instead of air cells; the mixed type,
consisting of a combination of the pneumatized and
diploic types; and the sclerotic or nonpneumatized/
nondiploic process. Owi ng to the considerable vari-
ation in the extent and location of the mastoid cells,
several terminologies have been used. The position
of the sigmoid sinus in the posterior cranial fossa
will influence markedly the position or occurrence of
all types.
Mastoid air cells may invade adjacent areas of the
temporal bone. Some of the more frequent extensions
form the hy\iotympanic cells, which lie in the plate of
bone separating the middle ear cavity from the jug-
ular bulb, and the epitympanic cells, which are exten-
sions into the roof of the middle ear. The latter group
may be extensive enough to include cells that will
invade the root of the zygomatic arch and the squa-
mous portion of the temporal bone.
The petrous apex of the temporal bone (i.e., that
part of the petrous portion anterior to the labyrinth)
may also be pneumatized, particularly by outgrowths
from the tympanic cavity. These cells, the petrous
apex cells, are necessarily related to the auditory tube
and the carotid canal.
The Facial Nerve in the
Temporal Bone
After traversing the internal acoustic meatus and
passing through the lateral end of that structure, the
facial nerve enters the bony facial canal (fallopian
canal). This canal continues laterally for a short
Pertinent Anat omy 17
The Inner Ear
The inner ear containing the essential cochlear and
vestibular mechani sms, lies within the petrous por-
tion of the temporal bone. The labyrinth of the inner
ear is surrounded by the bony otic capsule, which is
a unique structure for several reasons. It is formed
from 14 separate centers of ossification that fuse,
leaving no sutural lines. These centers, though
formed from cartilage, retain no areas of chondral
growth. In addition, the bone of the capsule retains
its fetal character, that is, typical haversian systems
I*
distance and brings the facial nerve to just above the
base of the cochlea, where it makes a sharp turn (the
external genii) to run posteriorly. The genu is also the
site of the. geniculate ganglion of the nerve, which
contains the cell bodies of the nerve's sensory com-
ponents. The genu and the ganglion are anterolateral
to the superior semicircular canal and between the
vestibule of the inner ear and the cochlea, and can
be easily localized from the middle ear as a point
situated just medial to the tip of the cochleariform
process. Continuing posteriorly with a slight infero-
lateral inclination, the bony canal forms the promi-
nence of the facial canal on the medial wall of the
middle ear. This prominence may be large enough
to partially cover the oval wi ndow and the base of
the stapes. The lateral wall of the canal in this part
is extremely thin and may be dehiscent. Behind the
base of the pyramidal emi nence the canal makes a
broad turn to descend vertically and somewhat lat-
erally through the mastoid process. In this descend-
ing or vertical portion the nerve may have a slight
anterior concavity. Relative to the exterior of the
skull, the canal normally lies deep to the sutural
groove between the tympanic and mastoid portions
of the temporal bone. It should be remembered that
there may be marked deviation from this "normal"
position, in which case the canal is usually situated
more posteriorly.
In its course from the brainstem through the facial
canal the facial nerve is supplied with blood by small
arteries derived from the anteroinferior cerebellar
branch of 4he basilar artery, the stylomastoid or
occipital branches of the external carotid, and the
petrosal arteries. There are apparently no anasto-
moses bet i een the labyrinthine blood supply and
these arteries, which seem to anastomose freely with
one another. Insufficiency of the vascular supply to
the facial nerve, from whatever cause, is regarded
by some as one of the primary causes of Bell's palsy.
18 Pertinent Anatomy
never develop. Finally, the capsule's maxi mum di-
mensions are attained by the fifth week of intrauter-
ine life.
The labyrinth of the inner ear is divided into
osseous and membranous components. The osseous
labyrinth, a system of bony canals within the otic
capsule, consists of three parts:
1. The vestibule, which forms the central portion of
the labyrinth; it is a relatively large, ovoid space
approximately 4 mm in diameter. Its characteristic
features include the following:
A. The elliptical recess, located on the floor of the
vestibule. It receives the anterior end of the
utricular portion of the membranous labyrinth.
B. The spherical recess, located anterior and
slightly inferior to the elliptical recess. It is the
site of the saccular portion of the membranous
labyrinth.
C. The vestibular whitlow, within the lateral w,.ll
of the vestibule.
D. Small orifices for the passage of nerves to the
vestibular portion of the inner ear. These a e
found on the medial wall and adjacent flo-,
where the vestibule abuts on the lateral erd
of the internal acoustic meatus.
2. The semicircular canals, which are continuous with
the vestibule. The anterior (superior) canal forms
the arcuate eminence on the bonv floor of the
middle cranial fossa. The posterior'canal has no
externally located landmarks associated with if.
Ihe lateral canal, as mentioned above, creates ,i
prominence in the region of the aditus of th.-
middle ear. All of the semicircular canals com
municate with the vestibule through both of thei-
crura. There are only five openings into the ves
tibule, however, since the posterior crus of th.
Pertinent Anatomy 19
anterior canal and the superior crus of the poste-
rior canal unite to form a single crus.
The canals have very definite planes of orien-
tation. The anterior is situated in the vertical plane
at an angle of 45 degrees with respect to the
sagittal plane of the skull, the posterior crura being
more medial. The posterior canal is also in the
vertical plane, at 45 degrees with respect to the
sagittal plane of the skull (that is, at 90 degrees
with respect to the plane of the anterior canal).
The lateral canal forms an angle of approximately
30 degrees with the horizontal plane, its anterior
end being highest, and is situated in the angle
between the anterior and posterior canals.
3. The cochlea, a cone-shaped, hollow, bony spiral of
about two and three quarters turns with a rela-
tively broad base and a pointed apex or cupula.
Its base lies against the anteromedial surface of
the vestibule and the lateral end of the internal
auditory meatus. Part of the basal turn of the
cochlea forms the promontory of the middle ear.
From its base the axis of the cochlea is directed
anterolaterals/ and slightly upward.
The central bony core of the cochlea is the
modiolus, through which nerves and vessels travel
to attain the structures of the cochlea. From the
outer surface of the modiolus the osseous spiral
lamina projects into the cavity of the cochlea,
partially subdividing the duct. It terminates at the
cupular end of the cochlea by projecting slightly
beyond the apex of the modiolus. This projecting
bony process of the lamina is the hamulus.
By convention, and for ease of reference and
description, the cochlea is described as if it were
sitting on its base with the apex pointing directly
up. Viewed in this orientation, it can be seen that
the spiral lamina is initiating the division of the
cochlear duct into an upper chamber, the scala
vestibuli, and a lower chamber, the scala tympani.
Only the scala vestibuli communi cates with the
vestibule of the inner ear; it also communi cates
with the scala tympani at the apex of the duct.
The scala tympani ends blindly at the round
window ( secondary tympanic membrane) of the
middle ear.
The osseous labyrinth is not a closed chamber;
there are several areas of communication with the
exterior. These include the following:
1. The vestibular aqueduct, extending through the
otic capsule from the vestibule to the posterior cranial
fossa. Its cranial end lies lateral to the internal acous-
tic meatus on the posterior surface of the petrous
portion of the temporal bone, where it is usually
overlaid by a scale of bone. This aqueduct trans-
mits the endolymphatic duct and an accompanying
vein.
2. The cochlear aqueduct, which begins in the scala
tympani of the basal coil of the cochlea near the
round window. This small canal terminates on the
inferior surface of the petrous pyramid, between the
jugular fossa and the external orifice of the carotid
canal. In the human it is not patent, being filled with
connective tissue.
3. The oval window, which is closed by the foot-
plate of the stapes and the associated annular liga-
ment.
4. The round window, closed by the secondary
tympanic membrane.
5. The fissula ante fenestram and the fossula post
fenestram, small clefts related to the vestibular win-
dow of the lateral wall. The fissula ante fenestram
usually extends completely through the bony lateral
wall of the vestibule, while the fossula does so in
only about 25% of all individuals. Both normally are
filled with connective tissue. The fissula is important
because of its predilection for otosclerotic bone for-
mation.
6 . The orifices of the nerves and vessels attaining
the inner ear.
Lining the entire osseous labyrinth is a layer of
periosteum or endosteum, which is continuous with
the periosteum of the cranium through the various
apertures and lies in close apposition to the walls of
the osseous labyrinth. The areas of modification that
merit further description occur within the cochlea.
At the free edge of the osseous spiral lamina the
endosteum is thickened to form the limbus, which
then divides into vestibular and tympanic lips sepa-
rated by a groove, the internal spiral sulcus. The
vestibular lip is confluent with the vestibular mem-
brane. The tympanic lip extends from the edge of
the osseous spiral lamina across the lumen of the
cochlea to the opposing peripheral wall, forming the
fibrous basilar membrane. It attaches peripherally to
the crest of the spiral ligament, which in turn is an
area of thickened, modified endosteum overlying the
lateral wall of the cochlea. While the basilar mem-
brane divides the lumen of the cochlea, it does not
extend all the way to the cupula but terminates just
before it, leaving a small area of communication
termed the helicotrenm between the scala vestibuli and
the scala tympani.
The membranous labyrinth is a system of delicate,
epithelium-lined channels surrounded by connective
tissue and lying within the osseous labyrinth (Fig.
1-9). Like its osseous counterpart, the membranous
labyrinth has vestibular, semicircular, and cochlear
components that communi cate with one another. The
membranous labyrinth exhibits certain general fea-
tures:
1. Its luminal capacity is much less than that of
the osseous labyrinth.
pO Pertinent Anatomy
is the most highly modified. Situated within the bony
cochlea, where it lies upon the upper surface of the
basilar membrane, it is a triangular duct extending,
the full length of the basilar membrane (but not to
the apex of the cochlea). Basally it is continuous with
the saccule through the ductus reuniens. The three
basic structural components of the cochlear due
include the following:
1. The vestibular membrane, which forms the roo,
of the cochlear duct and separates the endolymphatic
space of the duct from the perilymphatic space oi
the scala vestibuli. It is an extremely thin membrane
(approximately 0 . 0 0 3 mm).
2. The lateral wall, consisting of the sfrin vascularis,
a highly vascular region situated on the inner surface
of the spiral ligament. As its name implies, it is
characterized by its highly vascular nature and is
generally believed to be the source of endolymph.
3. The floor, consisting of the organ of Corti,
which is the sensory organ for hearing.
The Sensory Receptors of the
Inner Ear
Within the vestibular portion of the inner ear the
receptors consist of the following:
1. The cristae, located within the ampullae of thr
membranous semicircular canals. They consist oi
thickened epithelium containing neuroepithelial hai;
cells. Overlying the epithelium and extending to the
opposite wall of the ampulla is the gelatinous cupula.
The cilia of the hair cells project into the base of the
cupula.
2. The maculae, which are located in the utricle
and saccule and have similar structures. The hair
cells of the neuroepithelium are stiff, nonmotile pro-
jections embedded in an overlying gelatinous mem-
brane, the statoconic or otolithic membrane. This mem-
brane is unique in that it contains numerous crystals
termed otoliths.
The sensory portion of the cochlear duct, the organ
of Corti or spiral organ, has the same basic structure
as the cristae and maculae. It lies upon the basilar
membrane and consists of supporting cells and hair
colls overlaid by a gelatinous tectorial membrane. The
supporting cells are of several different types; how-
ever, all contain fibrils within their cytoplasm, and
their free edges form a reticular membrane against
which the tectorial membrane rests. The most im-
portant of the supporting cells are the phalangeal cells,
arranged in a single inner row, and an outer group
consisting of three to five rows depending on the
Pertinent Anatomy 21
level of the cochlea under consideration, there being
more rows apically than basally. The inner row is
associated with a single row of hair cells, while the
outer group has phalangeal cells alternating with
rows of hair cells. Between the inner and outer group
of phalangeal cells is an intercellular space extending
the entire length of the spiral organ and termed the
tunnel, inner tunnel, or canal of Corti. It is bounded
by special supporting cells designated the inner and
outer pillars (Corti's rods). Together the pillars and
the canal form Corti's arch. Peripheral to the phalan-
geal cells are other supportive elements, the tall cells
of Hensen and the shorter, more peripherally located
cells of Claudius.
The hair cells of the spiral organ have numerous
"hairs" projecting from their reticular surface (40 to
10 0 per cell). The innermost of these cells are long
and are thought to be the least sensitive to sound.
In contrast, the outer hair cells are short, being
wedged between the apical portions of the phalan-
geal cells.
able variation in the pattern of branching of the
labyrinthine artery. Any one of the normal branches
may be missing or may arise via a common trunk
with another branch.
Descriptions of the venous drainage of the inner
ear conflict. In all probability most are accurate,
reflecting a considerable but normal variation. The
described patterns include the following:
1. A vein of the vestibular aqueduct, draining most
of the semicircular canals and emptying into either
the sigmoid or the inferior petrosal dural sinus.
2. A vein of the cochlear aqueduct, draining the entire
cochlea and vestibule. It runs in a long canal paral-
leling the cochlear aqueduct to enter the superior
bulb of the internal jugular vein or the inferior
petrosal dural sinus.
3. A labyrinthine vein, which seems to be inconsis-
tent. When present, it drains the apical and middle
coils of the cochlea and traverses the internal acoustic
meatus to become tributary to the inferior petrosal
dural sinus.
Vascular Supply of the Inner Ear
The primary source of blood to the inner ear is
the Inbi/riiiHiine (internal auditory) artery. While this
vessel is usually described as originating from the
basilar artery, it probably arises more frequently from
the anterior inferior cerebellar artery. In addition, it
may be duplicated by terminal branches that arise
independently to enter the internal acoustic meatus.
In its course the labyrinthine artery accompanies
nerves VII and VIII through the internal acoustic
meatus. Its main branches run in the endosteum of
the labyrinth, and small branches traverse the tra-
becul e to gain the membranous labyrinth. Appar-
ently there are no functional anastomoses between
these two areas of distribution.
The most common first branch of the labyrinthine
artery is that which is distributed to the utricle, part
of the saccule, and the anterior ends of the anterior
and lateral semicircular canals. This branch has been
called both the anterior vestibular and vestibular artery.
When there is an apparent doubling of the labyrin-
thine artery, it is this branch that most frequently
arises independently. The other two common
branches of the labyrinthine artery are the vestibulo-
cochlear (posterior vestibular) artery, which is distrib-
uted to the saccule, the posterior semicircular canal
and parts of the anterior and lateral canals, part of
the utricle, and the entire basal coil of the cochlea;
and the cochlear nrlcry, which is distributed to the
remaining portion of the cochlea. There is consider-
Nerves of the Inner Ear
Before describing the innervation of the inner ear
we will consider the fundus of the internal acoustic
meatus. The fundus is divided into superior and
inferior portions by a horizontal bony ridge termed
the transverse crest. Located posteriorly within the
smaller superior depression are a number of small
foramina that transmit the nerves to the utricle and
the ampullae of the anterior and lateral semicircular
canals. This is the superior vestibular area. Anteriorly
within the upper depression is a relatively large
foramen that transmits the facial nerve. In the larger
inferior depression, immediately under the posterior
end of the transverse crest, is the inferior vestibular
area, which contains small foramina transmitting the
nerves to the saccule. Below and slightly posterior to
the inferior vestibular area is the foramen singulare,
through wiiich nerves pass to gain the ampulla of
the posterior semicircular duct. Anteriorly the infe-
rior depression is occupied by the foraminiferous spiral
tract, a series of minute foramina arranged in spiral
fashion that appose the base of the cochlea and the
modiolus. At the center of the spiral is the somewhat
larger orifice of the modiolar canal.
The nerve of the inner ear is the vestibulocochlear
(statoacoustic, acoustic, or auditory) nerve. Function-
ally, it consists of two divisions:
1. The vestibular division, containing fibers arising
from the vestibular ganglion, a sensory ganglion situ-
ated at the lateral end of the internal acoustic meatus.
'' 1. The membranous labyrinth tends to be placed
peripherally within the osseous labyrinth; it is sur-
jounded by the perilymphatic space (and perilymph).
In most locations this space is traversed by numerous
(Jelicate trabeculae extending from the endosteum to
e membranous labyrinth. The exception to this is
in the cochlea, where the trabeculae are very much
(educed or absent.
3. The membranous labyrinth contains the recep-
jpt s for hearing and equilibration.
4. It is a self-contained system with no patent
communication with other areas.
5. The membranous labyrinth contains endo-
lymph.
Individual Components of the
Membranous Labyrinth
The vestibular portion of the membranous laby-
rinth is characterized by two large dilatations, the
Hfricfe and saccule. The utricle, located in the posterior
portion of the osseous vestibule, receives the crura
of the three membranous semicircular canals. From
its anterior end arises the minute utricular duct
through which it communi cates with both the en-
dolymphatic duct and the saccule. Situated within
the utricle on its floor and lower lateral wall is the
macula, one of the receptor sites of the vestibular
system. The saccule is located anteromedial to the
utricle within the osseous vestibule. From its poste-
rior aspect arises the small saccular duct that is contin-
uous with the utricular duct (hence, utriculosaccular)
and the endolymphatic duct. Anteriorly the saccule
is continuous with the cochlear duct through the
extremely small ductus reuniens. The saccule has a
macula located on its lateral wall.
The endolymphatic duct arises from the union of the
utricular and saccular ducts and passes through the
vestibular aqueduct to terminate in a blind dilatation,
the endolymphatic sac, within a dural cleft on the
medial surface of the petrous portion of the temporal
bone. Within the sac are extensive folds of epithelium
with cores of vascular connective tissue, which would
seem to indicate that this particular site is the region
"'greatest physiologic activitv.
The membranous semicircular canals conform closely
to the configuration of their osseous counterparts.
At the anterior ends of the anterior and lateral canals
a
nd at the posterior (inferior) end of the posterior
canal are prominent dilatations or ampullae, which
house the receptor sites (cristae).
The cochlear portion of the membranous labyrinth
22 Pertinent Anatomy
These sensory fibers form the superior and inferior
vestibular news . The superior vestibular nerve sup-
plies the ampullae of the anterior and lateral semicir-
cular canals plus the maculae of the utricle and
saccule. Hence, it is this nerve that enters the inner
ear through the superior vestibular area of the fundus
o f the meatus. The inferior vestibular nerve supplies
the ampulla of the posterior semicircular canal and
the macula of the saccule. It is associated with the
inferior vestibular area and the foramen singulare of
the meatal fundus.
2. The cochlear division, consisting of fibers arising
from the spiral ganglion, which is situated in the coils
of the modiolus at the base of the osseous spiral
lamina. These fibers pass through the lamina to gain
the organ of Corti. Within the internal meatus these
fibers are associated with the foraminiferous spiral
tract and orifice of the modiolar canal.
Associated with the nerves of the inner ear is the
bundle of Oort, a small number of efferent fibers
arising from the superior olive of the brainstem.
These fibers run from the brainstem to the inner ear
within the inferior vestibular nerve, then pass ovet
to join the cochlear nerve. Although it is assumed
that these fibers are distributed primarily to the
cochlea, where they may play a part in some sort of
feedback mechani sm, their exact function has yet t;
be determined.
CHAPTER 2
Pertinent Histology
This short chapter presents four photomicro-
graphs of horizontal temporal bone sections at dif-
ferent levels. The sole purpose is to provide a general
orientation in terms of temporal bone anatomy; these
sections are useful in achieving the three-dimensional
visualization necessary for temporal bone surgery. A
detailed description of horizontal temporal bone sec-
tions is beyond the purpose of this atlas. The hori-
zontal sections are also to be used as references for
the pertinent! histopathologic slides described in this
book, which* for practical reasons are included in
their specific chapters rather than grouped together
here.
When describing horizontal sections of temporal
bones, "superior" means cephalad; "inferior" is cau-
dad; "anterior" is ventral; "posterior" is dorsal; "lat-
eral" is toward the external ear canal; and "medial"
is away from' the external ear canal.
24 Pertinent 1 listology
FIGURE 2 - 1
This section is in the area of the epi tvmpami m It
is important to remember that the middle car cavitv
extends superiorly above the tympanic membrane It
is at this level that the malleus can be laterally fixed
(not shown in this section). The wide communication
between the middle earand mastoid can be observed
as can the close proximity of the incus and horizontal
(lateral) semicircular canal to the aditus and antrum
At this high level the tensor tympani occupies the
anterior wall and is in close proximity to the facial
nerve ( FN), which is surrounded by a thin plate of
bone that is sometimes dehiscent. It is also important
to recognize the thinness of the bone plate separating
the vestibule from the internal auditory canal (pnrall'c'
r,vw>). I his must be kept in mind when doing .-
/abyrinthcctomy, since it is very easy to accidentally
create a fistula with subsequent cerebrospinal fluir
leak during this procedure. Note in these section-
the air space that exists in the normal mastoid cavity
compared with that in temporal bones with otitr
media (see Chapter 10) .
At this higher level, the nerves of the internal
auditory canal are the facial nerve anteriorly and the
superior division of the vestibular nerve posteriorly.
Pertinent Histology 25
FIGURE 2 - 2
This section is at the level of the stapes footplate,
which is bound to the oval window by the annular
ligament. The short distance from the footplate to
the contents of the vestibule (utricle and saccule)
should be noted. There is very little room ( 1 . 5 to 2 . 0
mm) to work with a Hough hoe (or similar instru-
ment) when removing the footplate without touching
vestibular structures. At this level the FN is located
posterior to the oval window; dehiscence (sometimes
bulging) is not uncommon at this site. This should
be remembered when working in this area.
This section also provides guidance for placing
tubes in the superior quadrants of the tympanic
membrane. The risk of damaging the incus or leaving
it directly exposed to the exterior by placing a tube
in the posterior superior quadrant is obvious in this
section; the safe placement in the anterosuperior
quadrant is more evident in Figure 2 - 3 .
The tendon of the tensor tympani can be observed
inserting^laterally over the anteromedial surface of
the manubrium of the malleus. It is here that the
tendon of the tensor tympani is sectioned (when this
procedure is needed). The body of the incus is
reduced in diameter at this level to form the body of
the descending long crus (long process of the incus).
The posterior incudal ligament can be observed as it
attaches at the fossa of the incus (fossa incudis). At
this level the nerves of the internal auditory canal
are the cochlear nerve anteriorly and the inferior
division jf the vestibular nerve posteriorly.
26 Per t i nent Hi s t o l o g y
F I G UR E 2 - 3
I n t hi s s ect i on t he ext er nal e ar canal and t y mpa ni c s hi p b e t we e n t he po s t er i o r s e mi c i r c u hr canal H
t he t hi n pl at e of b o ne t hat s e par at e s b o J s t r u c t u r e s m i c o ^ r X"^ Xet *
An i mpo r t ant f eat ur e i n t hi s s ect i on i s t he r el at i on-
Per t i nent Hi s t o l o g y 27
F I G UR E 2 - 4
At t hi s l o wer l evel i n t he me s o t y mp a n u m t he
pr o mo nt o r y i s cl ear l y appar e nt , as i s t he t y mpa ni c
me mb r a n e i n its full ho r i z o nt al ext ent . Thi s s ect i on
pr o vi d e s a cl ear i mag e of t he mi d d l e ear s pac e
ant er i o r l y a nd po s t er i o r l y f or pl a c e me nt of t ubes i n
t he i nf eri or q u ad r ant s . The s i nus t y mpa ni can be
o bs e r ve d and t he di f f i cul t y of cl eans i ng i t adequat el y
i f i t i s i nvo l ved wi t h c hr o ni c di s eas e can be s een. In
t hes e f o ur f i gur es t he t hi nnes s o f t he mu c o pe r i o s -
t e u m s ho u W be no t ed as a r ef er ence for c o mpar i s o n
wi t h t he pat ho l o g i c s l i des s ho wn i n speci f i c c hapt e r s .
CHAPTER 3
Pertinent Concepts in
High Resolution
Temporal Bone Imaging
Computed Tomography and
Magnetic Resonance Imaging
Hi g h r e s o l ut i o n c o mp u t e d t o mo g r a p h y ( CT ) a nd
ma g n e t i c r e s o n a n c e ( MR ) i ma g i ng h a v e dr a ma t i c a l l y
e n h a n c e d t h e fiel d o f t e mpo r a l b o n e i ma g i ng . Th i n
s e c t i o n a xi a l a nd c o r o na l CT pr o v i de s de t a i l e d v i e ws
o f t h e o s s i c l e s , b o n y l a b y r i nt h , c o c h l e a , a nd ma s t o i d
ai r c e l l s ( Fi gs . 3 - 1 t o 3 - 5 A ) . MR pr o v i de s s upe r i o r
s of t t i s s ue c o nt r a s t r e s o l ut i o n o v e r CT a nd o f t e n
e l i mi na t e s t h e n e e d f or i nv a s i v e pr o c e dur e s s uc h a s
a r t e r i o gr a ph y a nd p n e u mo c i s t e r n o g r a p h y ( Fi gs . 3 -
5 B t o 3 - 9 ) . T h e mul t i pl a na r c h a r a c t e r i s t i c s o f MR
pe r mi t de mo ns t r a t i o n of s of t t i s s ue a n a t o my i n any-
de s i r e d pl a ne o f pr o j e c t i o n, a nd i ma gi ng pa r a me t e r s
ma y be a dj us t e d t o fit e a c h pa r t i c ul a r c a s e . Thi n
s e c t i o n CT i s r e c o mme n d e d wh e n e v e r b o n y s t r uc -
t ur e s ne e d t o be v i e we d i n de t a i l . T e mp o r a l b o ne
i nj ur i e s , d e v e l o p me n t a l a no ma l i e s , o t o s c l e r o s i s , a nd
i nf l a mma t o r y mi ddl e e a r o r ma s t o i d l e s i o ns a r e be s t
s t udi e d wi t h CT , but MR i s t h e pr o c e dur e o f c h o i c e
f or e v a l ua t i o n o f i nt e r na l a udi t o r y c a na l ma s s l e s i o ns .
Vascular Ultrasound for
Atherosclerosis Screening
Hi gh r e s o l ut i o n r e a l - t i me dupl e x ul t r a s o und witrf.
D o p p l e r a nd s pe c t r a l a na l y s i s i s a us e f ul a nd c o s t -
e f f e c t i ve s c r e e ni ng pr o c e dur e f or c e r vi c a l c a r o t i d a t h -
e r o s c l e r o s i s . Re a l - t i me ul t r a s o und pr o v i de s di r e c t
vi s ua l i za t i o n o f t h e c e r vi c a l c a r o t i d a r t e r i e s ( Fi gs . 3
10, 3 - 11). Do ppl e r a nd s pe c t r a l a na l y s i s de f i ne f l o w
pa t t e r ns a nd ve l o c i t y . T h e s e no ni nv a s i v e s c r e e ni ng
pr o c e dur e s a r e e a s i l y pe r f o r me d upo n pa t i e nt s wi t h
c o mmo n c o mpl a i nt s s uc h a s " d i z z i n e s s " o r "l i gh t -
h e a d e d n e s s , " pr e c l udi ng t h e ne e d f or a r t e r i o gr a ph y
i n mo s t c i r c ums t a nc e s . MR s h o ws i mme n s e pr o mi s e
f or no ni nv a s i v e s t udy o f t h e i nt r a c r a ni a l v e s s e l s ( s e e
Fi g. 3 - 7 8 , C) .
P e r t i ne nt Co n c e p t s i n Hi g h Re s o l ut i o n T e mp o r a l B o n e I ma g i n g 2 9
FIGURE 3 - 1. , a u M o c a n a l ( i a ) . v e s i i b u | e ( o p e n a m w ) . The geniculate
Normal temporal bone (1.5 mm thick axial LI images, w ?oo; r n , , | m a l l P , head (lane curved arrow) and incus body
handle of malleus (curved arme); normal mastoid air cells Mule arrows).
FIGURE 3-2. , ,
Mondini deformity in a child with congenital deafness. The
deformed cochlea (arrow) is globular in configuration and is con-
tinuous with the deformed vestibule fourni rtrnite). Note an
operative defect (ic/iilc imam) from previous exploratory surgery.
J P e r t i ne nt Co n c e p t s i n Hi g h Re s o l ut i o n Te mpo r a ] B o n e J mo g i ng P e r t i ne nt Co n c e p t s i n Hi gh Re s o l ut i o n T e mp o r a l B o n e i ma g i n g 3 1
FIGURE 3 - 5.
Intraconalicular acoustic schwan-
noma shown with coronal CT (A)
and MRt (R) A, There is marked
expansion of the ny;ht internal au-
ditory canal (arrow). 8, Expansile
mass Cornue) is isointense with
brain <TR = WX), TI! = 20 ).
FIGURH y-b.
Paraganglioma ol the temporal hone demonstrated with carotid
arteriography Oronlal pru)eclion). An intense tumor blush (forge
arrow*) is mh-ii within the temporal bone on this common carotid
injection \ 'o<c cn}jrHc\ l cxfcrn.il carotid artery brandies (<-iti;;\t
arrow*) Wading into the tumor. Internal carol id artery also js
show n
y-lCURl: 3-7
Non-chrum.iMin paraganglioma (chemodecloma, of jugular Nir-
amen cj using tinnitus, hearing low ,ind paresis <,il cranial ne e >
l(! to 12 -\. Axial '-mm thiik nn.i^i
1
shows si^n-il-intense i. -is>
tltu^c iiHivci hi uiti-roiuedial tmiptM.il 'rone ( IK 2>lHl, 1.
10 }. iff,C-i-shows normal cmhlear .u|iieduet. n\ C . Cor nal
im.i^cs show hvpoinlense n i ,t-s i .iMiybf \chitr inrow*) i itli
ociluded internal jugular vein <N,uk mverrO ( IR HtKl, Th
-11) IV tit-notes normal opposite internai jugular vein C u rti
iiitt'.r in !! shows fluid in the middle ear caused hv a tu "or
ill'slritv i mg the cms,.uhi.in tube
P e r t i ne nt Co n c e p t s i n Hi gh Re s o l ut i o n T e mp o r a l Bo n e I ma g i n g 3 3
FICIUKL
Cholesterol granuloma ol the medial petrous ,ipe\ (surgically
i nfi rmi ' I). A, /!. Axial 3 mm thick images ( IR - 21100, TH =
2(1 [A\ and KO [8]) demonstrate a complex, signal-intense mass
(arrow) \sCi(hin the medial petrous apex. Noie considerable hy-
pointenv." material within the flmcKonlainmg mass in R. C,
Coronai r-mm image demonstrates the signal-intense mass < forge
arrow) d lorming the left internal auditorv ^anal umU arww)
from below (TR - 80 0 , TH = 20 ).
P e r t i ne nt Co n c e p t s i n Hi gh R s o l ut i o n T e mp o r a l B o n e I ma g i ng P e r t i ne nt Co n c e p t s i n Hi g h Re s o l ut i o n T e mp o r a l B o n e I ma g i n g 3 5
FIGURE .1-10 .
A longitudinal ultrasound imam' ol' the carotid bifurcation (10
MHz transducer). An irregular, calcific plaque (open arrow) at the
origin of the internal carotid artery (ICA) causes moderate narrow-
ing of the proxim.il vessel lumen. Normal external carotid artery
( ECA). Note the acoustic shadow (arrow) caused by calcium within
the plaque.
I IGL'Kl. ^ I I
Advanced carotid atherosclerosis with internal carotid artery (ICA)
stenosis. A lan;e, circumferential calcific plaque (lumws) causes
stenosis o( the proximal internal carotid artery. Normal external
carotid artery ( ECA). Note the acou.stic shadow (lur^c \rrow) from
heavilv calcified plaque.
SECTION II
Temporal Bone
Dissection
CHAPTER 4
Temporal Bone Removal
Knowledge of the human temporal bone is essen-
tial for the study of anatomy, histology, and pathol-
ogy, and for the practice of microscopic surgical
dissection. This knowledge helps provide a solid
basis for medical and surgical treatment, and allows
rational innovations and progress. It is useful for the
surgeon to learn how to remove a temporal bone
adequately. The specimen removed should contain
the external auditory canal, middle ear, mastoid,
inner ear structures, and surrounding petrous pyra-
mid.
Technique
T he cal\ ariuni is opened and (ho brain K exposed.
I he brain is then removed, care being taken to
section cranial nerves Vll and VIII sharplv at the
surface of the internal auditorv meatus (I ig. 4 - M) .
Thus the nerve trunks remain with the temporal
bom- specimen. 1 he two most common methods of
removal arc (1) the block method and (2) the bone
plug method
Block Method (Fig. 4 - 1 B)
A motor-driven saw or, preferably, a Strvker saw*
(rocker-type oscillating saw) is used. Four saw cuts
are made. The first (1) is made at a right angle, as
close to the apex of the petrous bone as the regional
anatomy will allow. If the cut is made further anterior
the eustachian tube can be removed. The second cut
(2) is made parallel to the first, through the mastoid
"Available frnm Ihr Orthopedic Fnime Comp.inv, K.il.im.i/uo.
MI.
process and as close to the lateral wall as possible.
The third cut (3) is made approximately 2.5 cm
anterior and parallel to the petrous ridge in the floor
of the middle cranial fossa. It includes the bony
external ear canal. The fourth cut (4) is made in the
horizontal plane, close to the floor of the posterior
cranial fossa. This undermining cut severs the bone
from its inferior attachments. The temporal bone is
still not loose, and great care must be taken to avoid
fracturing it.
A "lion-jawed" forceps is used to grasp the spec-
imen, and the remaining bony connections are loos-
ened by a gentle rocking motion that will free the
specimen for further dissection. A sharp chisel, knife,
or scissors is used to cut the remaining ligamentous,
fibrous, and bony attachments.
Whether the temporal bone is removed by the
block method or the bone plug method, the carotid
artcrv should be ligated and a suture placed in the
external auditorv canal to prevent anv leakage of
fluid
Bone Plug Method (Schuknecht's)
This technique requires the use of a specially
designed oscillating bone plug saw attached to the
conventional Stryker apparatus. The procedure is
simple and provides an adequate specimen. For the
adult skuli, a 1.5-in diameter saw adjusted to a depth
of 1.5 in is used; a 1-in diameter saw adjusted to a
depth of 1 in is used for smaller skulls.
The saw should be centered over the arcuate
eminence (superior semicircular canal prominence or
the superior surface) (Fig. 4-2/1) and directed to the
floor of the middle cranial fossa. The skull is held by
an assistant, and a stream of water is directed at the
40 T e mp o r a l Bo n e R e mo v a l T e mp o r a l Bo n e R e mo v a l 4 1
42 Temporal Bone Removal
Temporal Bone Removal 43
blade for lubrication (Fig. 4- 2S) . Cutting is completed
when a loss of resistance is felt, indicating penetra-
tion through the base of the skull. An improved
cutting action is obtained by slight rotation of the
saw. The plug is then grasped with the "lion-jawed"
forceps (Fig. 42C), and the bone is rotated, permit-
ting visualization of the internal carotid artery on its
inferior surface. The artery is ligated. Additional
attachments are sectioned with a knife, scissors, or
osteotome.
Fresh temporal bones can be wrapped in water-
sealed cotton or placed in Teflon bags; the air is
expelled and the bones are frozen. This helps to
preserve the soft tissues for later use.
General Setup and Equipment
A temporal bone dissection station (Fig. 4- 3 )
should be arranged to simulate actual operating room
conditions as closely as possible. Essential items of
equipment include a proper table, a comfortable
chair, an operating microscope, a motor-driven drill
or other otologic drill, suction apparatus, an assort-
ment of otologic instruments, and a temporal bone
holder. A list of suggested instruments appears be-
low.
In general, two types of temporal bone holders
are most commonly used: one that embeds and fixes
the temporal bone in a medium such as plaster of
Paris, and another that secures the temporal bone
specimen with specially designed screw holders,
allowing study of all surfaces and relationships of
the bone during dissection.
List of instruments and Materials
Operating microscope
Drill with a set of
cutting burs
Bulb syringe
Suction
Suction tips No. 1 and
No. 5
Stapes curets
Straight canal knife
Sickle knife
Joint knife
Straight pick
Stapes bending die
Hough hoe
Residents with imaginati
these instruments and ma
instruments and selecting
than those suggested
Whirlybird
Small alligator forceps
Fenestrometer
Scalpel
4-0 silk ( mounted on
curved needle)
0 .0 5-mm stainless steel
wire
Silastic sheeting
Gel foam
TORP, PORP, PE tube
Scissors (small plastic)
Ossicle holder
Measuring rod
on can obviate many of
terials by adapting broken
similar, cheaper materials
CHAPTER 5
Surgical Procedures
T h e gui de l i ne s i n t h i s c h a p t e r h a v e b e e n de s i gne d
f or t h e pr a c t i c a l pur po s e o f b e i ng r e a d a n d f o l l o we d
a s t h e di s s e c t i o n pr o c e e ds . T h e y a r e i nt e nde d t o
s e r v e a s a di a l o gue b e t we e n t h e i ns t r uc t o r a nd t h e
s ur ge o n di s s e c t i ng t h e t e mpo r a l b o n e . Ai ms , h i gh -
l i gh t s , pi t f a l l s , pe r t i ne nt a n a t o my , a nd s ur gi c a l s t e ps
a r e di s c us s e d dur i ng t h e di s s e c t i o n i n a n a t t e mpt t o
s i mul a t e a r a t i o na l pr o c e dur e .
T h e a ut h o r s e n c o ur a g e di s s e c t i o n o f t e mpo r a l
b o n e s a s a n e s s e nt i a l pr e r e qui s i t e for o t o l o gi c t r a i ni ng
i n r e s i de nc y pr o g r a ms o r f or o t o l a r y ngo l o gi s t s wh o
wi s h t o pr a c t i c e s pe c i f i c t e c h ni que s . Th i s pr a c t i c e ,
pl us a k n o wl e d g e o f a n a t o my a n d h i s t o pa t h o l o gy , i s
e s s e nt i a l f or de v e l o pi ng r a t i o na l a nd no t me r e l y
i mi t a t i ve me a n s o f s ur gi c a l t r e a t me nt .
T h e s uc c e s s i o n o f pr o c e dur e s h a s b e e n o r ga ni z e d
for t h e f ul l es t ut i l i za t i on o f t h e b o n e s . F o ur " we t "
t e mpo r a l b o n e s a r e ne e de d for full c o mpl e t i o n o f
t h e s e gui de l i ne s .
Wh e n de s c r i b i ng o r di s c us s i ng a t e mpo r a l b o n e
di s s e c t i o n pr o c e dur e , " s upe r i o r " me a n s t o wa r d t h e
t e mpo r a l l i ne ( c e ph a l a d) ; "i nf e r i o r " i s t o wa r d t h e
ma s t o i d t i p ( c a uda d) , " a nt e r i o r " i s t o wa r d t h e e xt e r -
nal a udi t o r y c a na l ( ve nt r a l ) ; " po s t e r i o r " i s a wa v f r om
t h e e x t e r na l a udi t o r y c a na l ( do r s a l ) ; "l a t e r a l " i s t o-
wa r d t h e ma s t o i d c o r t e x ( s upe r f i c i a l ) ; a nd " me d i a l "
i s a wa y f r om t h e ma s t o i d c o r t e x ( de e p) .
Simple Mastoidectomy
Aim
Ex e nt e r a t i o n ( r e mo v a l ) o f al l ma s t o i d ai r c e l l s wh i l e
ma i nt a i ni ng t h e i nt e gr i t y o f t h e po s t e r i o r c a na l .
Highlights
1. Us e t h e mi c r o s c o pe at all t i me s .
r
2. Dr i l l unde r di r e c t vi s i on, a v o i di ng " h o l e s " ( c r i l i
e v e nl y ) .
3. Wh e n i n do ub t , i de nt i f y l a ndma r ks a nd us i ,
ma s t o i d c ur e t .
4. D e v e l o p a gr a dua l , s t e p- b y - s t e p pr o c e dur e .
5. T h i n k a na t o mi c a l l y a nd t h r e e - di me ns i o na i v.
L o o k for s t r uc t ur e s ; do no t "f i nd t h e m. "
6 . Ke e p a n a t o mi c a b e r r a t i o ns i n mi nd ( h i gh s. g-
mo i d s i nus , a nt e r i o r s i gmo i d s i nus , Ko r ne r ' s s e p t u m,
e t c . ) .
Pitfalls
1. Fa i l i ng t o i de nt i f y t h e a nt r um.
A. Ko r ne r ' s s e p t um.
B. I ns uf f i c i e nt t h i nni ng of t h e t e g me n a nd/ o r p s -
t e r i o r o s s e o u s c a na l .
2. I nj ur i ng a h i gh s i gmo i d s i nus .
3. I nj ur i ng t h e f aci al ne r v e by go i ng
A. D e e p t o t h e h o r i zo nt a l s e mi c i r c ul a r c a na l .
13. T o o far a nt e r i o r i n t h e di ga s t r i c r i dge .
4. Di s l o c a t i ng t h e i nc us by dr i l l i ng bl i ndl y i nt o t " , e
a nt r um a r e a .
Surgical Steps
As s es s External Aliatomi/ ( Fi g. 5 - 1 ) . P l a c e t h e t e m-
por a l b o ne i n s ur gi c a l po s i t i o n ( s i mul a t i ng i t s no r m i l
a na t o mi c l o c a t i o n f or s ur ge r v ) . Vi s ua l i ze a nd s t u n '
S ur gi c a l P r o c e dur e s 45
Spi ne of Henl e
Mast oi d tip
t h e l a t e r a l s ur f a c e ( c o r t e x) i n its e nt i r e t y f r om t h e
t e mpo r a l l i ne ( l i ne a t e mpo r a l i s ) s upe r i o r l y t o t h e
ma s t o i d t i p i nf e r i or l y. I de nt i f y t h e po s t e r i o r a s pe c t
o f t h e o s s e o us c a na l a nt e r i o r l y . No t e t h e pr e s e nc e o f
t h e s upr a me a t a l s pi ne ( s pi ne o f He nl e ) i mme di a t e l y
po s t e r i o r t o t h e o s s e o u s c a na l . R e v i e w t h e i ma gi na r y
l i ne s t h a t o ve r l i e t h e ma s t o i d a nt r um, t h a t i s , b e -
t we e n t h e t e mpo r a l l i ne a nd s pi ne o f He nl e ( f os s a
ma s t o i de a o r Ma c e we n ' s t r i a ngl e ) . I ma g i ne t h e i nne r
s t r uc t ur e s of t h e ma s t o i d c a vi t y i n a t h r e e - di me n-
s i o na l f a s h i o n a nd t r a c e y o ur s ur gi c a l pl a n.
Initiate Drilling ( Us e Large Burs, Sauccrize). Empl o y -
i ng t h e mi c r o s c o pe , us e a l a r ge b ur a nd s t ar t s a uc e r -
i zi ng i n a n e v e n f a s h i o n, b e g i n n i n g a t t h e f os s a
ma s t o i de a unt i l ai r c e l l s a ppe a r ( Fi g. 5 - 2 A) . Ma k e a
wi de c or t i c a l r e mo v a l , i nc l udi ng t h i nni ng o f t h e po s -
t e r i o r c a na l . As y o u go de e pe r , k e e p t h i nki ng o f y o ur
f ut ur e l a ndma r ks t o o r i e nt y o ur s e l f t o wa r d t h e a n-
t r um. Yo u r s upe r i o r l i mi t i s t h e t e g me n ma s t o i d e um
( l e ve l o f t e mpo r a l l i ne ) , s upe r i o r t o wh i c h l i es t h e
dur a o f t h e mi ddl e c r a ni a l f os s a . Th i n t h e t e g me n
d o wn , b e i ng c a r e f ul t o k e e p i t i nt a c t ; t h i s i s i mpo r t a nt
i f a de qua t e a c c e s s t o t h e a nt r um i s i nt e nde d. T h e
po s t e r i o r c a na l wa l l s h o ul d b e t h i nne d d o wn a s we l l
for t h e s a me pur po s e . Aga i n, dr i l l i ng s h o ul d r e ma i n
e v e n a t al l t i me s , no t s t r a i gh t b ut o r i e nt e d a nt e r i o r l y
t o wa r d t h e no s e o f o ur i ma gi na r y pa t i e nt . Ou r a n-
t e r o s upe r i o r l i mi t i s t h e r o o t o f t h e z y g o ma t i c pr o c -
e s s . T h i s s h o ul d b e o p e n e d wi t h o ut o pe ni ng t h e
e p i t y mp a n u m.
Identify the Lateral Sinus (Sigmoid Sinus). In dr i l l i ng
po s t e r i o r l y y o u wi l l e n c o u n t e r t h e s i gmo i d s i nus
( l a t e r a l s i nus ) ( Fi g. 5 - 2 B ) . I t i s i de nt i f i e d i n s ur ge r y
by its b l ui s h c o l o r a nd s mo o t h b o n y pl a t e . ( In t h i s
46 Sur gi cal Pr o c e d u r e s
l-'IGURK 5-2.
Sur gi cal Pr o c e d u r e s 47
di s s ect i o n we ar e l ooki ng for t he s mo o t h bo ny pl at e. )
The s e char act er i s t i cs ar e t he bes t g ui des t o t he si g-
mo i d s i nus . A c ha ng e i n t he s o u nd of t he bur s i s a
hel pf ul hi nt but d o e s not suf f i ce as a gui de; vi sual i -
z at i on far o u t we i g hs s ens at i o n i n t e mpo r al b o ne
s u r g e r y. I t mus t be r e me mb e r e d t hat t he s i g mo i d
s i nus d o e s not have a uni f o r m a na t o my ; i t c an be
hi gh ( l at eral ) o r l o w ( medi al ' deep) . The s u r g e o n
s ho ul d be caut i o us wi t h t he us e of t he dri ll. I nt eri -
or l y, t o war d t he mas t o i d t i p, t he ai r cells ar e t o be
dri l l ed evenl y wi t h t he l evel of dri l l i ng s uper i or l y.
Li t t l e by li ttle, a t ypi cal ki d ne y- s hape d mas t o i d cavi t y
b e c o me s evi dent .
Identify Korncr's Septum mid Antrum. In pr o c e e d i ng
medi al l y ( d e e pe r d o wn ) , o ccas i o nal l y o ne ma y en-
c o u nt e r a t hi ck pl at e of b o ne t hat ma y gi ve t he
i mpr e s s i o n o f havi ng r e ac he d t he a nt r u m. Thi s i s
K r ne r ' s s e pt u m, a sol i d pl at e t hat r e pr e s e nt s t he
f us i on o f t he s q u a mo u s and pe t r o u s po r t i o ns o f t he
t e mpo r al bo ne. Wh e n i n do ubt , g o back t o yo u r
pr evi o us l y i dent i f i ed l and mar ks and s t r uct ur es , ver -
ify y o u r l ocat i on, and i mag i ne t he b o ne t hr e e - d i me n-
s i onal l y al o ng wi t h t he s us pe c t e d ar ea o f t he a nt r u m.
Us i ng mas t o i d cur et , cur et s uper i o r l y and po s t er i o r l y
unt i l i dent i f yi ng t he " t r u e a n t r u m. " Th e a nt r u m i s
po s t e r o s u pe r i o r t o t he o s s e o u s canal . A c o mmo n
e r r o r i s t o go t o o far bel o w t he t e mpo r al li ne o wi ng
t o l ack of t hi nni ng of t he pl at e. An i mpo r t ant gui de-
l i ne i s t hat t he a nt r u m s ho ul d be r e ac he d or e nt e r e d
f r om abo ve i f d a ma g e i s t o be avo i ded. O n c e t he
a nt r u m i s i dent i f i ed, avo i d u nc o ve r i ng t he i ncus ;
i dent i l v t he ho r i z o nt al s emi ci r cul ar canal , whi ch i s
o n e of t he mo s t i mpo r t ant l and mar ks . At t hat poi nt ,
vi m kno w t hat vou a r c def i ni t el y i n t he a nt r u m and
t hat vo u a r c s uper i o r t o t he l aci al ne r v e . K you ar e
unabl e t o s ec t he i nc us , wo r k . i nt eri orl y just i nf eri or
t o t he d u r a ol t he t c g mc i i , t i ns i s t he wi des t di s t ance
be t we e n t he os s i cl es ani l c pi l vmpanu ni .
Identify ami f V/ mr the Snmluntl Angle, Hard Angle,
and racial , \ Vi w ( Fi g. 3 - 3 ) . Drill pos t er i or l y, t hi nni ng
t he s i gmo i d s i nus , and be t we e n t he s i nus and t he
t e g me n pl at e unt i l t hey me e t i n a s ha r p ang l e ( s i no-
dur al ang l e or Ci t el l i ' s angl e) . Co nt i nu e dri l l i ng i n-
t er i or l y t o war d t he mas t o i d t i p, e xe nt e r at i ng cel l s
f r om t he di gas t r i c r i dge ar ea. Ke e p i n mi nd t hat t he
faci al ne r ve and its poi nt of exi t f r om t he s t yl o mas t o i d
f o r ame n ar e i mme d i at e l y ant e r i o r t o t he di gas t r i c
r i dge. At t hi s poi nt , we ar e left wi t h an i nt act ar ea
i n t he s o- cal l ed " har d ang l e " ( an ar ea co nt ai ni ng t he
po s t er i o r s emi ci r cul ar canal i n t he pl at e t hat over l i es
t he po s t er i o r cr ani al f os s a, and an uni dent i f i ed f aci al
ne r ve ) . I t i s i mpo r t ant t o r e mai n ab o ve t he ar e a of
t he ho r i z o nt al s emi ci r cul ar canal . The l ocat i on o f t he
ho r i z o nt al canal al l o ws e x po s u r e of t he f ossa i ncudi s
( and s ho r t pr o c e s s of t he i ncus ) i nf erol at eral l y t o t he
a nt r u m a nd t he ho r i z o nt al canal , t he e pi t y mpa nu m,
and al s o t he ext er nal g e nu o f t he faci al ner ve, whi c h
i s medi al t o t he ho r i z o nt al s emi ci r cul ar canal .
Us i ng a f e ne s t r o me t e r , me a s u r e an i mag i nar y t ri -
ang l e 1 0 mm f r om t he t i p o f t he s ho r t pr o ces s o f t he
i ncus or f os s a i ncudi s , al o ng t he axi s of t he hor i z ont al
s emi ci r cul ar canal ( 3 0 d e g r e e s f r om t he t e g me n) , and
1 2 mm f r o m t he f os s a i ncudi s at an angl e o f 4 5
d e g r e e s f r o m t he t e g me n. Thi s ar ea i dent i f i es and
i s ol at es t he har d angl e ( co nt ai ni ng t he po s t er i o r s emi -
ci r cul ar canal ) ( Fi g. 5 - 3 C) . I mme d i at e l y i nf eri or t o i t
and ant e r i o r t o t he s i g mo i d ( l at eral s i nus ) i s t he pl at e
of b o ne t hat over l i es t he d u r a of t he po s t er i o r cr ani al
f os s a, wh e r e t he e nd o l ymphat i c s ac i s f o und. N o w
i dent i f y Tr a u t ma nn' s t r i angl e ( Fi g. 5 - 3 D) , b o r d e r e d
by t he l at eral s i nus ( s i gmo i d s i nus ) , t e g me n, a nd
s emi ci r cul ar canal s . Thi s t r i angl e i dent i f i es t he l oca-
t i on of t he po s t er i o r cr ani al f os s a.
The faci al ne r ve i s i dent i f i ed but not unr o o f e d .
We will c o me back t o i t f ur t her i n t he di s s ect i on. The
s i mpl e ma s t o i d e c t o my i s n o w c o mpl e t e d , t hat is, all
ai r cel l s ha v e been r e mo v e d ( except t ho s e i n t he
pe t r o u s a pe x ) . Rei dent i f y all a na t o mi c s t r uc t ur e s ,
l a nd ma r ks , t r i angl es , and angl es .
Endolymphatic Sac Surgery
Aim
To i dent i l v and e x po s e t he e nd o l ymphat i c s ac
o ver l vi ng t he d u r a ma t e r o f t he po s t er i o r cr ani al
f os s a.
Highlights and Surgical Steps
1 . Co mpl e t e s i mpl e ma s t o i d e c t o my ( al r eady per -
f o r me d ) .
2. Dri l' t o, but not bel o w, t he d o me of t he ho r i -
z ont al s emi ci r cul ar c anal .
3 . I dent i f y, pr e s e r ve , and me a s u r e t he har d ang l e
co nt ai ni ng t he po s t er i o r s emi ci r cul ar canal .
4. I dent i f y t he pos i t i on of t he s i gmo i d s i nus a nd
its r el at i o ns hi p t o Tr a u t ma nn' s t r i angl e.
5. De c o mpr e s s t he l at eral s i nus and di s s ect t he
i nf r al abyr i nt hi ne cell t r act .
6 . I nci s e t he e nd o l y mpha t i c s ac, pr o be its l u me n,
and pl ace Si l ast i c s heet i ng .
4 6 Surgical l'rocedures
H C; UKL 5 - 1 .
Surgical Procedures 49
Pitfalls
1. Skeletonizing or damaging the posterior semi-
circular canal.
2. Insufficient unroofing of the dural plate.
3. Failing to identify the endolymphatic sac and
its lumen.
4. Damaging the incus.
5. Depositing debris in the middle ear.
6 . Lateral sinus bleeding.
Procedure
In endolymphatic sac surgery, the authors advo-
cate a thorough simple mastoidectomy (which has
already been done). In our dissection, we have al-
ready identified the bone plate overlying the poste-
rior cranial fossa dura. Redefine Trautmann's trian-
gle, identify the hard bone containing the posterior
semicircular canal, and measure the distances again
(Fig. 5-4B): 10 mm from the tip of the short process
of the incus or fossa incudis, along the axis of the
horizontal semicircular canal (30 degrees from the
tegmen); 12 mm from the fossa incudis at an angle
of 45 degrees from the tegmen. Drill into the infra-
labyrinthine cell tract to help expose the sac location.
Pav special attention to the position of the sigmoid
sinus. On occasion it partially overlies the dural plate,
reducing the size of Trautmann's triangle. The plate
is thinned down to eggshell thickness, then gently
elevated and separated from the underlying dura
with a duckbill elevator. The sac is identifiable as a
thickened white area of the dura over the thin sur-
rounding dura (Fig. 5- 5). The posterior semicircular
canal shoud not be thinned or skeletonized. Drilling
is done immediately inferior to this area. The sac
comes toward the dura from the direction of the
posterior semicircular canal. If the lateral sinus is in
such a position that it tends to partially cover the
dura or make access to it difficult, first recheck the
position of the bone; the "head" might be bent too
far forward. If the sinus is still prominent after
repositioning of the "head," it should be decom-
pressed by removing part of its bony covering facing
the dura. Infralabyrinthine cells might have to be
drilled (leading toward the jugular bulb). The sac is
incised gently with a sickle knife and the lumen
probed with a Whirlybird.
Facial Recess Approach,
Posterior Tympanotomy
Aim
Removal of air cells immediately lateral to the
facial nerve at the external genu (facial recess collec-
tion of air cells).
Highlights
1. Define the landmarks clearly.
2. Thin the posterior canal wall.
3. Drill parallel to facial nerve fibers.
4. If fhe approach is troublesome, combine trans-
mastoid and transcanal visualization.
PitfaVs
1. Damaging the facial nerve.
2. Perforating the bony external ear canal.
3. Perforating the tympanic membrane.
4. Those of a simple mastoidectomy.
Procedure
Define your landmarks (Fig. 5-6 /4). The external
genu of the facial nerve is medial; the fossa incudis
is superior. Thin the posterior canal wall. Identify
the facial nerve by its pearly white color underneath
the thin layer of bone. The bone is still too thick;
thin it down very carefully by drilling parallel to the
direction of the facial nerve fibers (Fig. 5- 6 8) . Small
cutting burs should be used since the recess is quite
small. Inferiorly, identify the chorda tympani (which
is to be preserved) as it leaves the facial nerve in an
anterosuperior direction; it then takes a lateral direc-
tion toward the annulus (Fig. 5-7A). On occasion,
the facial recess is quite small and the procedure
difficult. Rather than insisting on taking unnecessary
risks, use a combined transcanal-transmastoid ap-
proach.
Text continued on nage 54
5U Surgical Procedures
Hori zont al canal
H GUKI . n 4
Surgical Procedures 51
i I GURI :
S ur gi c a l P r o c e dur e s
FIGURI; 5 li
S ur gi c a l P r o c e dur e s 53
Hori zont al faci al nerve
FIGURE 5-:
54 S ur gi c a l P r o c e dur e s
O n c e t h e r e c e s s i s o p e n e d , t h e l a ndma r ks a r e
r e i de nt i f i e d: t h e e x t e r na l g e nu o f t h e f aci al ne r v e i s
me di a l ; t h e f os s a i nc udi s i s s upe r i o r ; t h e c h o r da
t y mpa ni i s i nf e r o l a t e r a l a nd po s t e r i o r ; a n d t h e t y m-
pa ni c me mb r a n e i s a nt e r o l a t e r a l .
No w o b s e r v e t h e f o l l o wi ng s t r uc t ur e s ( Fi g. 5 - 7 B ) ;
t h e h o r i zo nt a l po r t i o n o f t h e f aci al ne r v e , t h e l e nt i c -
ul a r p r o c e s s o f t h e i nc us , t h e i nc udo s t a pe di a l j o i nt ,
t h e c a pi t ul um o f t h e s t a pe s , a n d t h e s t a pe di a l t e n-
d o n . Ne x t i de nt i f y t h e p r o mo n t o r y , a nd i nf e r o me -
di a l l y t h e r o und wi n d o w ni c h e .
Cochlear Implant (Facial Recess
Approach)
Aim
To pl a c e a n e l e c t r o de i nt o t h e c o c h l e a b y s l i di ng i t
t h r o ugh t h e r o und wi n d o w. ( We wi l l de a l o nl y wi t h
i nt r a c o c h l e a r e l e c t r o de pl a c e me nt a n d wi t h e l e c -
t r o de s t ha t a r e pl a c e d far i nt o t h e i nt e r i or o f t h e
c o c h l e a . )
Highlights
1. F. ns ur e go o d vi s ua l i za t i o n e i a an a de qua t e l . ui al
r e c e s s a ppr o a c h .
2 . Cl e a r l v i de nt i l v t h e r o und wi n d o w ni c h e a nd
r o und wi n d o w me mb r a n e .
Pitfalls
1. [ h o s e of t h e f aci al r e c e s s a ppr o a c h i t s el f .
2 . I na de qua t e vi s ua l i za t i o n o f t h e r o und wi n d o w,
wi t h t h e e l e c t r o de una b l e t o b e pa s s e d b e y o n d t h e
h o o k.
Surgical Steps
1. T h o s e of a s i mpl e ma s t o i d e c t o my a nd facial
r e c e s s a p p r o a c h .
2. P r e pa r e a s e a t f or t h e i nt e r na l r e c e i v e r .
3. I ns e r t t h e i nt r a c o c h l e a r e l e c t r o de .
Procedure
At t h i s po i nt i n t h e di s s e c t i o n, t h e ma i n dr i l l i ng
f or t h e pr o c e dur e h a s been d o n e . Yo u a r e l=ft wi t h
i ns e r t i ng t h e e l e c t r o de t h r o ugh t h e r o und v i ndo w
a n d dr i l l i ng a s e a t f or t h e i nt e r na l r e c e i v e r po s t e r o -
s upe r i o r t o t h e ma s t o i d c a vi t y . Lo c a t e a p o s
;
i o n f or
t h e i nt e r na l r e c e i ve r ; i t s h o ul d be i mme di a t e l y po s -
t e r i or t o t h e po s t e r i o r l i mi t o f t h e dr i l l e d Mas t o i d
c a vi t y , wi t h i t s a nt e r i o r ( t o wa r d t he e a r c a na l ) b o r de r
no f ur t h e r t h a n wh e r e t h e b o r de r o f t h e i m: gi na r y
pi nna ( a ur i c l e ) wo u l d be i f i t we r e p u s h e d pc s t e r i or
( t h a t i s , i mme di a t e l y po s t e r i o r t o t h e po s t e r i o r o o r de r
o f t h e pi nna ) . S upe r i o r l y , t h e b o r de r s h o ul d not b e
a b o v e t h e s upe r i o r b o r de r o f t he pi nna . Dr i l l a s e nt ,
us i ng a s a gui de l i ne t h e c i r c umf e r e nc e of t h e i nt e r na l
r e c e i v e r of y o ur pr a c t i c e e l e c t r o de ( Fi g. 5 - 8 ) . I f a
pr a c t i c e e l e c t r o de i s no t a va i l a bl e , dr i l l a s e a t i nt o
wh i c h a ni c ke l - s i ze d c o i n wo ul d fit. Dr i l l i ng c a n be
d o n e c a r e f ul l y wi t h a r e gul a r bur , or i t c a n be d o n e
wi t h e i t h e r a but t e r f l y b ur or a b ur s pe c i a l l y de s g n e d
by o n e of t h e c o c h l e a r i mpl a nt ma nuf a c t ur e r s [ f a
s c r e w t y pe of i nt e r na l r e c e i v e r i s t o be us e d, dr il l
f our h o l e s i n t h e c o r r e s po ndi ng o p e n i n g s o f the b a s e
of t h e pe de s t a l t o a ma x i mu m de pt h of 2 mm.
Re g a r dl e s s of t h e t y pe of i nt e r na l r e c e i v e r , wi t h a
s ma l l b ur dr i l l t wo s ma l l h o l e s i mme di a t e l y s upe r i o r
a nd i nf e r i or t o t h e l o c a t i o n o l y o ur a l r e a dv d i l l e d
s c a t , t hat is, t wo h o l e s s upe r i o r l v a nd t wo h o l e s
i nf e r i or l y ( Fi g. 5 - 9 / 1 ) . Br i ng t he s ma l l h o l e s t o ge t h e r
v c r v c a r e f ul l y , t h e n pa s s 2- 0 s i l k t h r o ugh t h e s -
o p e n i n g s (I ig. 5
l
' / i ) ; t hi s u ill he us e d to crus*. o v e r
t h e i nt e r na ! r e c e i \ o i a mi s eat i t i n pl a c e . Do mi l pl a t e
\ o ur i nt e r na l r e c e i v e r vol .
Ou r a t t e nt i o n i s no w t ur ne d h a c k t o t h e a. l i ve
e l e c t r o de Aga i n, \ i s u , i h / c t h e r o und wi n d o w I-P h e .
II vi s ua l i za t i o n is not , ul e. | u, i t o a t r . ms c ana I app- - >a. h
t a n h e n u d e \ c i i l v t he o pe ni ng o t t h e r o und wi n-
d o w i mh e On o c c a s i o n, i t i s nc c e s s . i r v or us e . ; I t o
ge nt l v dr il l t he . i nt e r i or b o r de r ol t he ni c h e ( I i ; . 5-
y ( ' ) . I h i s wi l l pr o v i de a s l i gh t l y l a r ge r o p e n i n g ". t h
b e t e r vi s ua l i za t i o n, a nd at t h e s a me t i me wi l l pr. i cnt
a "s t r a i gh t s h o t " at t h e c o c h l e a , s ki ppi ng t h e ' o o k
po r t i o n t ha t s o me t i me s i s di f f i cul t t o b y pa s s . P o s ( i on
t h e e l e c t r o de i n t h e o p e n i n g o f t he wi n d o w a nd h e n
ge nt l y pus h i t i n, us i ng a b l unt pi ck or wi r e gui c e or
o n e of t he s pe c i a l e l e c t r o de gui de s pr o v i de d by t h e
i mpl a nt ma nuf a c t ur e r s ( Fi g. 5 - 1 0 ) . I f t h e r e i s s u n e
r e s i s t a nc e , i t i s l i ke l v t ha t t h e e l e c t r o de i s c a ug h up
i n t h e h o o k. Re t r a c t t h e e l e c t r o de ge nt l y a nd t r t o
r o t a t e it, wh i l e i ma gi ni ng t h e di r e c t i o n o f t h e c o c h - e a .
On t h e l eft, f or e x a mp l e , t ur n ge nt l y t o wa r d t h e r ' ? h t
( c l o c kwi s e ) ; on t h e r i gh t , t ur n ge nt l y t o wa r d t h e ' eft
7V.v( tvntiiiiicd on paee 59
S ur gi c a l P r o c e dur e s 55
FIGURE 5-8
Surgical I' rocedures
15mm
Facial nerve
Surgical Procedures 57

In scala tympani
B
Scala tympani
A
'. <'-' /'SIrf,'/'h.
e
'\

Round window niche ' .
A
(
'"
:'
"
B
o
56
FIGURE 0- J(J
HCL R K 5- 11
Surgical Procedures 59
(counterclockwise). Place the electrode and then se-
cure the internal receiver with either screws or su-
tures (Fig. 5- 11).
Transmastoid Facial Nerve
Decompression
Highlights and pitfalls are discussed in the text.
Surgical Steps
1. Those of a simple mastoidectomy.
2. Identify the different segments of the facial
nerve, and skeletonize the fallopian canal.
3. Fracture and remove any bony covering.
4. Open the sheath of the facial canal.
Procedure
In the course of the complete simple mastoidec-
tomy, the vertical portion and external genu of the
facial nerve were fairly well delineated. For practical
surgical purposes the facial nerve can be divided into
three segments: (1) that within the internal auditory
canal; (2) the tympanic segment (horizontal/middle
ear); and (3) the vertical segment (mastoid). We will
deal now with the vertical and horizontal segments,
in that order.
From the external genu, the nerve proceeds ver-
tically to the stylomastoid foramen at the level of the
anterior edge of the digastric ridge (Fig. 5- 12). It is
important to visualize its anatomy and, if possible,
compare it with cither bones, since there is consid-
erable variation. The nerve is lateral to the horizontal
canal; however, it may have a posterior projection at
the genu, lending itself to potential damage. It is
useful to visualize the nerve anterior to the digastric
ridge and to appreciate how lateral it becomes as it
reaches the mastoid tip. Its tympanic or middle ear
segment appears in the region of the cochleariform
process at the geniculate ganglion, then runs poste-
riorly towards the oval window (stapes) to a point
just inferior and usually medial (deep) to the hori-
zontal semicircular canal.
The vertical segment can be dissected from the
level of the fossa incudis or from the digastric ridge.
From the ridge it can be followed superiorly to the
external genu; however, this is not a reliable land-
mark. Although this approach is perfectly acceptable,
the authors tend to follow nerves peripherally rather
than centrally, which seems both safer and simpler.
After visualization of the genu, the canal is skele-
tonized all the way down to the stylomastoid fora-
men. Drilling is done in strokes parallel to the direc-
tion of the nerve (superior to inferior or vice versa).
Exposure of the tympanic segment is helped by
enlarging the aditus ad antrum. This dissection, plus
enlargement of the facial recess approach, allows
visualization anteriorly toward the cochleariform
process. Visualize the segment at the level of the
oval wi ndow and the pyramidal eminence. This is a
very useful image to keep in mind. If necessary,
adequate 'isualization can be obtained by a combined
approach. Visualize the tympanic segment through
the canal. It is also possible to obtain adequate
visualization by removing the incus (Fig. 5- 13A).
Before disarticulating the incus, try to drill under it
without damaging or dislocating it, using the smallest
possible burs. Now try to remove and replace the
incus. If drilling toward the geniculate ganglion was
incomplete, drill now without the incus in place.
(The incus should be left in place for use in the next
procedure; however, practice placing and replacing
the incus to become familiar with its normal anatomic
position.) Once the entire facial canal has been
thinned to eggshell consistency, fracture it with a
pick and lift the bone fragments gently with a Whirly-
bird without using the facial nerve as a fulcrum (Fig. 5 -
138). The sheath is then opened with a sharp sickle
knife (Fig. 5-13C).
Canalplasty (Fig. 5- 14)
Aim I
Enlargement of the bony canal and visualization
of the enhre fibrous and bony annulus.
Pitfalls
Excessive drilling of the anterior wall and entrance
into the temporomandibular joint space.
6 0 S ur gi c a l P r o c e dur e s
['IGL'Ri: 5- 12
6 2 Surgical Procedures
Ant. canal wal l
Tympani c membrane
A Post, canal wal l
I Ant erosuperi or
quadrant
B
FIGURI: s-14
Procedure
Surgical Procedures 6 3
Using a large bur, drill the canal wall evenly until
visualization of the entire fibrous annulus is achieved
(Fig. 5-14A). Do not drill in one spot, but "sweep"
the bur gently with even pressure and go one step
at a time. (Skin procedures will not be dealt with,
since the skin is thick, tight, and difficult to elevate
adequately for these purposes in harvested temporal
bones.)
Underlay Graft of the Tympanic
Membrane
Aim
Placement of a graft under the tympanic mem-
brane, covering all edges of the perforation.
Procedure
Vi s ual i ze t he t v mpa ni c me mb r a n e . I mag i ne i t i n
f our q u ad r ant s ( Fi g. 5 - 1 4 R) . Us i ng a s t rai ght pi ck
and a si ckl e kni f e, ma ke a cent r al per f or at i on ( Fi g.
3 - 1 5 / 1 ) . Fill t he mi ddl e ear s pac e wi t h Ci el f oam ( Fi g.
5 - 1 5 / t ) . Obt ai n a pi ece of f asci a ( or pape r ) t hat
e x c e e d s t he si ze ol t he per l o r at i o n bv at l east 1 0 ' . ; .
Scari f v t he u nd c r s u r f ac c o f t he t v mpa ni c me mb r a n e
a r o u nd t he per l o r at i o n, us i ng a H o u g h ho e. No w
pl ace t he graft o ve r t he per f or at i on and pos i t i on i t
medi al l y bv us i ng t he H o u g h ho e ( Fi g. 5 - 1 5 C D).
Ossiculoplasty (Incus Procedures)
Aim
Restoration of ossicular chain continuity (in this
case, where incus problems are the cause of the loss).
Remove the "graft," the entire tympanic mem-
brane, and the Gelfoam filling the cavity. Now vis-
ualize the cavity and what is found beneath the
different quadrants (see Fig. 5- 14B). Familiarize
yourself with the anatomy. Mobilize the temporal
bone and learn what areas can be seen best at
different angles. Palpate the ossicles with a blunt
pick, and observe the round window niche area, the
opening of the eustachian tube, the stapedial tendon,
and other features. Compare the views of the middle
ear cavity with the transcanal and posterior tympan-
otomy approaches. The incus is already loose.
Clip the distalmost portion of the long process of
the incus ("necrosis of the lenticular process") (Fig.
5-16 A). Since the mastoidectomy has been done
already, remove a piece of "cortical bone" posterior
to the mastoid cavity opening. Using a small bur,
delineate a square of bone and remove it. Shape this
piece of bone in order to restore continuity. Drill a
small acetabulum for the head of the stapes and a
groove for the remaining long process of the incus
(Fig 5- 1 6 B- E) .
Remove the entire incus. Restoration of ossicular
continuity in this case can be achieved in a number
of ways (Fig. 5- 17). We will use a sculptured incus,
a sculptured cortical bone and, if available, a partial
ossicular replacement prosthesis ( PORP). Clip the
short process of the incus and drill an acetabulum in
the remaining long process, for fitting over the head
of the stapes. Then drill a groove over the remaining
body for fitting under the malleus. Now try to
sculpture a piece of cortical bone in this same shape.
Avoid contact of the incus graft with the promontory.
Try a PORP as well, if available.
Intact Bridge Mastoidectomy
(IBM), Modified Radical
Mastoidectomy, and Radical
Mastoidectomy
Aims
Exteriorization of the disease process within the
epi tympanum, antrum, and mastoid to the meatus.
Procedure
6 4 S ur gi c a l P r o c e dur e s
S ur gi c a l P r o c e dur e s 6 5
IMC.URI-: 5 1?.
Surgical Procedures 6 7
The IBM is a version of modified radical mastoidec-
tomy with bridge preservation, allowing tympano-
plasty repairs.
Highlights
1. Enlarging the anterior canal wall without open-
ing the temporomandibular joint, and visualizing the
entire fibrous and bony annulus.
2. Large meatoplasty is crucial for the success of
the procedure.
Pitfalls
1. Incomplete removal of the posterior meatal
wall..
2. Poor meatoplasty.
Surgical Steps
1. Meatoplasty.
2. Canalplasty.
3. Saucerize the mastoid circumferentially.
4. Enlarge the aditus and sculpture the bridge to
widen the mesotympanum.
5. Remove all disease.
6 . Preserve when possible the anterior tympanic
membrane and manubrium.
7. Use a ventilation tube.
8. Ossiculoplasty, tympanoplasty.
9. Obliterate the aditus with periosteum or car-
tilage.
10 . Obliterate the mastoid (usually not necessary).
11. Thiersch graft (at the primary procedure or 3-
4 weeks postoperatively).
Procedure
These procedures involve removal of the posterior
meatal wall. The original Bondy modified radical
mastoidectomy implies this step; however, in the
Bondy procedure the middle ear cavity is not entered.
Both the IBM and the modified radical mastoidec-
tomy imply entering the middle ear.
Intact Bridge Mastoidectomy
The "bridge" is the most medial portion of the
posterosuperior meatal wall; it is literally the bridge
that crosses the attic toward the tegmental area. It
has both anterior and posterior buttresses. The an-
terior buttress is the superior portion where the
posterior bony canal meets the tegmen. The posterior
buttress is the inferior portion where the posterior
bony canal meets the floor of the external auditory
canal, lateral to the facial nerve. Drill the anterior
canal wall, enlarging it until clearly visualizing the
entire fibrous and bony annulus but without entering
the temporomandibular joint space (Fig. 5-18/1).
Lower the posterior canal wall, leaving the bridge
intact (Fig. 5- 18B). Normally the facial recess is not
drilled open, but in our bone this has already been
done. Visualize and section the tensor tympanic
tendon (this maneuver lateralizes the manubrium)
(Fig. 5- 18C). At this point in a clinical case, you
would place a tube in the tympanic membrane rem-
nant and perform an ossiculoplasty, place a graft,
and obliterate the aditus with either periosteum or
cartilage.
Modified Radical Mastoidectomy
For practical purposes, a modified radical mastoid-
ectomy has already been performed, except that the
bridge is still intact. Removing the bridge will com-
plete the modified radical mastoidectomy.
There a r e two approaches for the modified radical
mastoidectomy: the "inside-out" or atticotomy ap-
proach, a nt the "outside-in" or atticoantrotomy ap-
proach. We have already performed, step by step,
an outside-in approach in this bone. In our next
bone, which will be used for middle ear dissection,
the inside-out modified radical mastoidectomy ap-
proach will be used.
Drilling is started in the epi tympanum and fol-
lowed posteriorly into the antrum. In doing this, the
bridge is removed. The antrum is identified, as well
as the dome of the horizontal canal (Fig. 5-19A).
With this landmark under direct vision, mastoidec-
tomy is performed and the posterior bony wall is
lowered to the level of the facial ridge (Fig. 5- 19B).
This method is easier and safer than the outside-in
approach in a sclerotic mastoid.
Radical Mastoidectomy (Fig. 5- 20 )
The purpose of this procedure is to create an
exteriorized cavity that includes the mastoid, antrum,
6 8 S ur gi c a l P r o c e d ur e s
S ur gi c a l P r o c e dur e s
FIGURE 5-19.
Sur gi cal Pr o c e d u r e s 71
e pi t y mpa nu m, and me s o t y mp a n u m, l eavi ng a d r y
epi t hel i al i zed cavi t y c o nt i nu o u s wi t h t he e xt e r nal
me a t u s . The pr o c e d u r e i nvol ves r e mo v i ng t he mal -
l eus a nd i ncus whi l e l eavi ng t he s t ape s i nt act . The
mu c o s a of t he mi d d l e e ar i s r e mo v e d as wel l .
Petrous Drainage
Aim
Exe nt e r at i o n ( r e mo val ) o f pe t r o u s ape x ai r cel l s
whi l e mai nt ai ni ng t he i nt egr i t y of t he i nner ear
s t r uc t ur e s .
The pe t r o u s a pe x ( pe t r o us pyr ami d ) has t wo maj o r
g r o u ps o f ai r cel l s, t he ant er i o r and t he po s t er i o r .
The po s t er i o r g r o u p ( Fi g. 5 - 2 1 4 ) i ncl udes cell t r act s
s uper i o r , po s t er i o r , a nd i nf eri or t o t he s emi ci r cul ar
canal s ; t he ant er i o r g r o u p ( Fi g. 5 - 2 1 6 ) i ncl udes cell
t r act s i n t he s u pe r o me d i al as pect of t he eus t achi an
t ube' o r i f i ce, whe r e t he car ot i d ar t er y i s l o cat ed. I n
o r d e r t o r each t hes e ant er i o r cell t r act s , a r adi cal
ma s t o i d e c t o my ( des cr i bed abo ve ) mu s t b e d o ne . H y -
po t y mpa ni c ai r cel l s al s o ar e pr e s e nt adj acent t o t he
r o u nd wi nd o w ni che.
Posterior Cell Tract
Fo r t hi s di s s ect i on, s kel et oni z at i on of t he s i gmo i d
s i nus , t he po s t er i o r f os s a d ur a, and t he faci al ne r ve
i s r equi r ed. This has al r eady been d o ne . Ou r next
s t ep i s t o ear cf ul l v s kel et oni z e t he s emi ci r cul ar canal s
( Fi g. 5 - 2 I C) . Us e s mal l bur s (."1-0 or 4- 0 s i ze) . Fo u r
ar e as o r t r act s , whi c h mav o r mav not be pr es ent ,
s ho ul d be l ooked l or. The first t ract i s t hr o ug h t he
ar ch ol t he s uper i o r s emi ci r cul ar canal I he s e c o nd
t ract i s ant e r o s u pe r i o r t o t he semi ci re ul ar c. t nal , l ead-
i ng i nt o t he s t i pr aco chl ear ai r c e l l s \ i svi ali ze t hi s t r act
and its r el at i ons hi p t o t he faci al ne r ve . The t hi rd t r act
i s po s t er i o r t o t he s uper i o r canal and r u ns be t we e n
t he t e g me n ma s t o i d e u m and c o mmo n cr us o f t he
me mb r a n o u s l abyr i nt h t o war d t he i nt er nal audi t o r y
canal . Do not e x po s e t he c o mmo n c r u s t hi s i s t o be
d o ne l at er. The i nt ent i on her e i s t o obt ai n a bet t er
vi s ual i z at i on of t hi s a na t o mi c r el at i ons hi p. The f our t h
or r et r o l abyr i nt hi ne cell t r act i s i nf eri or t o t he po s t e-
ri or s emi ci r cul ar canal , medi al t o t he ver t i cal s e g me nt
of t he faci al ne r ve , and s uper i o r t o t he j ug ul ar bul b.
Anterior Cell Tract
A r adi cal mas t o i d e c t o my has al r e ad y been d o ne .
The t e g me n s ho ul d be s kel et oni z ed and t he ant er i o r
wal l t hi nned; bot h o f t he s e pr o c e d u r e s have al r e ad y
been pe r f o r me d . The cel l s of t he ant er i o r t ract ar e
f o und i n t he "per i t ubal " and car ot i d ar e as i n t he
b o ny wal l just medi al t o t he eus t achi an t ube ori f i ce
ant er i o r t o t he pr o mo nt o r y . The s e cel l s ar e cl os el y
as s o ci at ed wi t h t he t e g me n mas t o i d e u m; t her ef or e,
di s s ect i on mu s t be d o ne ve r y car ef ul l y. The au t ho r s
pr ef er t o us e s mal l cur et s at t hi s l evel .
Labyrinthectomy (Transmastoid
Labyrinthine Dissection)
Aim
Co mpl e t e r e mo val o f t he s emi ci r cul ar canal s and
soft t i s s ue of t he ves t i bul e
Highlights
X. The s i no dur al ang l e mu s t be co mpl et el y
t hi nned for ad e q u at e e x po s u r e of t he ves t i bul e.
2. The t e g me n mu s t be t hi nned for ad e q u at e vi s-
ual i z at i on of t he s upe r i o r as pect of t he s emi ci r cul ar
canal s .
Procedure
The t hr e e s emi ci r cul ar canal s ar e s kel et oni z ed unt i l
t he me mb r a n o u s l abvr i nt h i s vi si ble t hr o ug h t he bo ne
as a t hi n bl ue li ne ( Fi g. 5 - 2 2 , 4 ) . No t e t he r el at i o ns hi p
of t he faci al ne r ve t o t he hor i z ont al s emi ci r cul ar canal
( Fi g. 5 - 2 2 / i ) . Fe ne s t r at e t he ho r i z o nt al canal . Unr o o f
t he po s t er i o r and ant e r i o r po r t i o ns o f t he s uper i o r
s emi ci r cul ar canal . Fo l l o w t he s uper i o r s emi ci r cul ar
canal unt i l . t r e ac he s its c o mmo n c r us wi t h t he
po s t er i o r s emi ci r cul ar canal . The ar c u at e ar t er y pen-
et r at es t he har d l abyr i nt h i n t he cent er of t he ar ch of
t he s upe r i o r s emi ci r cul ar canal . Go back t o t he s u-
per i o r s emi ci r cul ar canal , i dent i f y t he s uper i o r ves -
t i bul ar ne r ve , and f ol l ow i t i nt o t he i nt er nal aud i t o r y
me a t u s ( Fi g. 5 - 2 2 C) . Vi s ual i z e t he c o mmo n cr us .
No w i dent i f y t he e nd o l ymphat i c d u c t as i t e nt e r s t he
po s t e r o s u pe r i o r end of t he ves t i bul e. Veri f y its pr es -
e nc e and its di r ect i on t o war d t he e nd o l y mpha t i c s ac;
t hi s i s a us ef ul anat o mi c r el at i ons hi p t o ke e p i n mi nd,
s i nce t hi s ar ea i s not vi s ual i z ed i n e nd o l ymphat i c s ac
e nha nc e me nt pr o c e d u r e s . Bo ne i s no w r e mo v e d f r om
72 S ur gi c a l P r o c e dur e s
FIGURE 5 21
FIGURE 5-22.
74 S ur gi c a l P r o c e dur e s
t h e f l oor o f t h e v e s t i b ul e wh e r e t h e i nf e r i or v e s t i b ul a r
ne r v e i s e n c o u n t e r e d .
Fo l l o w t h e c o mmo n c r us a nt e r i o r l y i nt o t h e ve s t i -
b ul e . O p e n i t wi de l y a n d t r y t o i de nt i f y t h e me m-
b r a ne o f t h e ut r i c l e a nd s a c c ul e . No t i c e t h e r e l a t i o n-
s h i ps a nd di s t a nc e s b e t we e n t h e f o o t pl a t e , s a c c ul e
a nd ut r i c l e . No w s ke l e t o ni z e t h e r o und wi n d o w'
s i nc e t wo a ddi t i o na l o b s e r v a t i o ns c a n be ma l e i n
t h i s a r e a . Fi r s t , dr il l c a r e f ul l y a t t h e i nf e r i o r n. , r gi n
o f t h e r o und wi n d o w a nd i de nt i f y t h e s i ngul a r ne r v e
( Fi g. 5 - 2 3 / 1 ) . S e c o n d , dr il l t h i s a r e a a nd i de nt i f y t h e
h o o k o f t h e b a s a l t ur n o f t h e c o c h l e a ( Fi g 5 - / 3 B )
Co c h l e a r e l e c t r o de s ma y b e o b s t r uc t e d i n t h i s a r e a
wh e n b e i ng i ns e r t e d i nt o t h e c o c h l e a . Vi s ua l i ze i t s
Singular nerve
Ro und wi ndow
Co c h l e a ( b a s a l tur n)
S ur gi c a l P r o c e dur e s 75
a n a t o my i n o r de r t o s e e t h e di r e c t i o n i n wh i c h t h e
e l e c t r o de s h o ul d b e po i nt e d a nd t h e a mo u n t o f b o n e
t h a t s h o ul d be dr i l l e d t o b y pa s s t h e h o o k.
Middle Ear Dissection
Procedure
T h i s pr o c e dur e i s s t a r t e d wi t h a n e w we t b o n e .
S ki n pr o c e dur e s wi l l no t be de a l t wi t h s i nc e t h e s ki n
i s t h i c k, t i ght , a nd di f f i cul t t o e l e v a t e a de qua t e l y f or
t h e s e pur po s e s . I de nt i f y t h e wa l l s o f t h e e a r c a na l .
Vi s ua l i z e t h e t y mpa ni c me mb r a n e ; i ma g i ne i t i n f our
qua dr a nt s ( Fi g. 5 - 2 4 / \ ) . Ma k e o p e n i n g s i n t h e a nt e r o -
s upe r i o r , a nt e r o i nf e r i o r , po s t e r o i nf e r i o r , a nd po s t e r -
o s upe r i o r qua dr a nt s . No w ge nt l y e l e v a t e t h e t y m-
pa ni c me mb r a n e a nd i de nt i f y t h e a r e a s a nd
s t r uc t ur e s b e n e a t h t h e f our o p e n i n g s . Vi s ua l i ze wh a t
i s f o und b e ne a t h t h e po s t e r o s upe r i o r qua dr a nt o pe n-
i ng. No w b e nd t h e t v mpa ni c me mb r a n e f o r wa r d; i f
i t i s t o o br i t t l e , r e mo v e it. Vi s ua l i z e t h e mi ddl e e a r
( Fi g. 5 - 2 4 B ) . P a l pa t e t h e o s s i c l e s , J a c o b s o n ' s ne r v e ,
t h e r o und wi n d o w ni c h e a r e a , a nd t h e o pe ni ng o f
t h e e us t a c h i a n t ub e , a nd i de nt i f y t h e t e ns o r t y mpa ni .
R e mo v e t h e s ki n, l e a vi ng t h e a n n ul us i nt a c t . I de n-
tify t h e t y mp a n o s q u a mo u s s ut ur e s upe r i o r l y a nd t h e
t y mp a n o ma s t o i d s ut ur e po s t e r i o r l y . Be t we e n t h e s u-
t ur e s i s t h e v a s c ul a r s t r i p. I de nt i f y t h e a nt e r i o r wa l l
a nd c a r e f ul l v dr i l l t h e a nt e r i o r b o n v o v e r h a ng wi t h -
o ut e nt e r i ng t h e t e mp o r o ma n d i b u l a r j oi nt s pa c e .
Enl a r g e t h e c a na l unt i l t h e e nt i r e t v mpa ni c me mb r a n e
a n n ul us i s c l e a r l v vi s ua l i ze d ( Fi g. 5 - 2 4 C) .
Us i ng a l a r ge s t a pe s c ur e t , c ur e t t h e s c ut um f r om
s upe r i o r t o i nf e r i or , t h us a v o i di ng i nj ur v t o t h e
o s s i c l e s ( Fi g. 5 - 2 5 ) . Vi s ua l i ze t h e s t a pe di a l t e ndo n.
Ma k e s ur e i t i s c l e a r l v i n s i gh t . At t h i s poi nt y o u a r e
r e a dy f or a s t a pe de c t o my . I ns t e a d of s e c t i o ni ng t h e
s t a pe di a l t e ndo n ( wh i c h c a n be d o n e , a s we l l ) , t r y t o
lift i t a l o ng wi t h i t s pe r i o s t e um wi t h t h e i nc udo s t a -
pe di a l j o i nt kni f e , l e a vi ng i t a t t a c h e d t o t h e pe r i o s -
t e um o f t h e l o ng pr o c e s s o f t h e i nc us ( Fi g. 5 - 2 6 / 4 ) .
Th i s i s no t a s i mpl e pr o c e dur e . Us i ng t h e i nc udo -
s t a pe di a l j o i nt kni f e , s e pa r a t e t h e j o i nt v e r y ge nt l y .
Fr a c t ur e t h e f o o t pl a t e i n t h e mi ddl e wi t h a s t r a i gh t
pi c k ( Fi g. 5 - 2 6 B ) . Mo b i l i z e t h e s t a pe s , us i ng s upe r i o r -
t o- i nf e r i or a nd i nf e r i o r - t o - s upe r i o r mo v e me n t s , a nd
r e mo v e it, h o o ki ng t h e j o i nt kni f e t o t h e a r e a i mme -
di a t e l y i nf e r i or t o t h e c a pi t ul um ( Fi g. 5 - 2 6 C) . T h e
r e ma i ni ng f o o t pl a t e po r t i o ns a r e l i f t ed ge nt l y wi t h a
Ho u g h h o e ( Fi g. 5 - 2 6 D ) . Us i ng t h e wi r e b e ndi ng di e
0. 005 s t a i nl e s s s t e e l a nd Ge l f o a m, ma k e t h e pr o s -
t h e s i s a s de s c r i b e d i n Fi gur e 5 - 2 7 . P l a c e i t o v e r t h e
l o ng pr o c e s s o f t h e i nc us a nd ge nt l y c r i mp n o t t o o
t i gh t l y , no t t oo l o o s e l y a l l o wi ng i t s o me mo bi l i t y
s i nc e e x c e s s i v e t i gh t ne s s mi gh t r e s ul t i n ne c r o s i s o f
t h e l o ng pr o c e s s o f t h e i nc us . Ma k e a Te f l o n pi s t o n
( Ro s a l e s t e c h ni que ) a s de s c r i b e d i n Fi gur e 5 - 2 8 . P l a c e
t h i s pi s t o n pr o s t h e s i s o v e r t h e l o ng pr o c e s s o f t h e
i nc us a n d ge nt l y c r i mp it.
No w r e mo v e t h e i nc us . T r y t o ma k e a l o nge r
pr o s t h e s i s o f s t a i nl e s s s t e e l wi r e a nd Ge l f o a m t o
e x t e nd f r o m t h e ma l l e us t o t h e ova l wi n d o w ( Fi g. 5-
2 9 ) . Us e t h e i nc us t o ma k e a s t r ut f or us e b e t we e n
t h e ma l l e us a nd t h e s t a pe s . S e c t i o n t h e s h o r t pr o c e s s
o f t h e i nc us a nd dr i l l a n a c e t a b ul um o v e r t h e b o d y
s o t h a t i t wi l l fit unde r t h e ma l l e us . Us e a s ma l l gr af t
t o c o v e r t h e o va l wi n d o w.
At t h i s po i nt , wi t h t h e us e of a c ur e t or ve r y s ma l l
bur , c ur e t o r dr il l t h e a t t i c i n o r de r t o pe r f o r m a n
a t t i c o t o my . Us e a Wh i r l y b i r d t o pr o b e t h e a nt r um.
Cochlear Implant
(Mastoidotomy-Tympanotomy
Approach)
Aim
To pl a c e a n e l e c t r o de i nt o t h e c o c h l e a by s l i di ng i t
t h r o ugh t h e r o und wi n d o w.
Highlights and Surgical Steps
1. Ac h i e v e g o o d vi s ua l i za t i o n o f t h e mi ddl e e a r
a nd r o und wi n d o w ni c h e via a n e nda ur a l a ppr o a c h
( L e mp e r t 1 i nc i s i o n) .
2. P e r f o r m a n a t t i c o t o my .
3 . R e mo v e t h e i nc us .
4. Ex p o s e t h e ma s t o i d c o r t e x a nd dr i l l a ma s t o i d-
o t o my ( L e mpe r t I I i nc i s i o n) .
5. P e r f o r m a s ma l l po s t a ur i c ul a r i nc i s i o n a nd dr il l
a s e a t f or t h e i nt e r na l r e c e i ve r .
6. T u n n e l t h e e l e c t r o de f r om t h e po s t a ur i c ul a r
i nc i s i o n . o t h e ma s t o i d o t o my i nt o t h e a nt r um, mi ddl e
e a r , a nd r o und wi n d o w ni c h e .
7. S e c u r e t h e i nt e r na l r e c e i v e r i n pl a c e .
Text continued on ptigc 82
FIGURE 5-24
S ur gi c a l P r o c e d ur e s 77
Tympanosquamous suture
B
FIGURE 5-25
Ib
Surhica! l'rocl'durl'S
S u q ~ i c a l Procedures 79
B
Malleus to oval window
D
t---4 mm ---l
A
0.005 stajnJess steel wire
Gelfoam
-ff-......--.--,
Foolplate
B
A
c
FIGURE o-B
80 S ur gi c a l P r o c e d ur e s
FIC'.URl-' 5-28.
S ur gi c a l P r o c e dur e s
FIGURE 5-24
82 S ur gi c a l P r o c e dur e s
Procedure
Thi s pr o c e dur e i mpl i e s a n e nda ur a l a ppr o a c h ,
e x po s i ng b o t h t h e mi ddl e e a r a nd ma s t o i d c o r t e x.
O n c e t h e r o u n d wi n d o w ni c h e i s c l e a r l y e x po s e d a nd
de f i ne d, a n a t t i c o t o my ( Fi g. 5 - 3 0 A) i s d o n e a nd t h e
i nc us i s r e mo v e d . A s ma l l ma s t o i d o t o my i s pe r -
f o r me d ( Fi g. 5 - 3 0 C) . Th i s o pe ni ng wi l l a l l o w pa s s a ge
o f t h e e l e c t r o de i nt o t h e mi ddl e e a r t h r o ugh t h e
a n t r um ( Fi g. 5 - 3 0 E) . T h e r e c e i v e r i s pl a c e d a s i n t h e
po s t e r i o r t y mp a n o t o my a ppr o a c h ; h o we v e r , o nl y a
s ma l l po s t a ur i c ul a r i nc i s i o n i s ne e de d, a nd t h e e l e c -
t r o de i s t unne l e d a nt e r i o r l y t o wa r d t h e ma s t o i do t -
o my .
S i nc e t hi s i s a t e mpo r a l b o n e di s s e c t i o n, a n a t t e mpt
c a n be ma d e t o pl a c e t h e r e c e i ve r , pe r f o r mi ng a
ma s t o i d o t o my a nd pa s s i ng t he e l e c t r o de t h r o ugh t h e
a nt r um a nd i nt o t h e r o und wi n d o w ( Fi g. 5 - 3 1 ) . T h e
i nc us mus t b e r e mo v e d ( wh i c h h a s a l r e a dy b e e n
do ne ) . A ma s t o i d o t o my i s t h e c r e a t i o n of a n o pe ni ng
i n t h e f os s a ma s t o i de a wi t h o ut pe r f o r mi ng a c o m-
pl e t e c or t i c a l ma s t o i de c t o my . T h e b o n e i s dr i l l e d i n
t he di r e c t i o n o f t h e a n t r um by vi s ua l i zi ng t h e a t t i c
a r e a di r e c t l y t h r o ugh t h e mi ddl e e a r . I n o r de r t o
a s c e r t a i n t h e l o c a t i o n of t h e a nt r um, a Wh i r l y b i r d
c a n be us e d f or di r e c t pr o b i ng. Ev e n i f a ma s t o i do t -
o mv i s not pr e c i s e l y a c or t i c a l ma s t o i de c t o my , t h e
o p e n i n g s h o ul d be l a r ge e n o u g h ; a bl i nd, s ma l l
o pe ni ng i s da ng e r o us . T h e ma s t o i d o t o my i t s e l f i s a
us e f ul e x pl o r a t o r y t ool f or t h e a nt r um wh e n b l o c ka ge
i s s us pe c t e d o r i mpr o v e d a e r a t i o n o f t he mi ddl e e a r
i s de s i r e d. I ns e r t i o n of t h e e l e c t r o de t h r o ugh t he
r o und wi n d o w i s t h e s a me a s i n t h e po s t e r i o r t y m-
p a n o t o my a ppr o a c h ; t h e e l e c t r o de i s pa s s e d t h r o ugh
t h e o pe ni ng i nt o t he c o c h l e a .
Transcanal Lahyrinthectomy
Procedure
Vi s ua l i ze t h e mi ddl e e a r c a vi t y ( Fi g. 5 - 3 2 ) . I dent i f y
t h e ova l a nd r o und wi n d o ws a nd pr o mo nt o r y , a s
we l l a s t h e f aci al ne r v e . Hi e pur po s e o f t hi s pr o c e -
dur e i s t o de s t r o y t h e l a b y r i nt h . T h e s t a pe s f oot pl a t e
h a s b e e n r e mo v e d , a nd t h e v e s t i b ul e c o nt a i ni ng t he
s a c c ul e a nd ut r i c l e i s e x p o s e d . Bv t h e us e of a h o o k
o r Ho u g h h o e , t h e s a c c ul e c a n b e de s t r o y e d ( Fi g. 5 -
3 3 A) . Us i ng t h i s s a me r o ut e , t h e a mp u l e o f t h e
s upe r i o r s e mi c i r c ul a r c a na l c a n b e r e a c h e d a b o v e a nd
i n f r ont of t h e facial ne r v e , t ha t of t he po s t e r i o r c a na l
b e l o w a nd b e h i nd t h e ne r v e , a nd t h e a mpu; e o f t h e
h o r i zo nt a l c a na l i nf e r i or l y b e ne a t h t h e ne r v t ( Fi g. 5-
3 3 / 1 , B) . I n t hi s pr o c e s s , t h e ut r i cl e i s de s t o y e d a s
we l l . I t i s i mpo r t a nt t o s t a y wi t h i n t h e b o ny . onl ' i ne s
a nd t o de s t r o y o nl y t h e " me mb r a n o u s l a b / r i nt h . "
I mme di a t e l y i nf e r i or t o t h e ve s t i bul e i s t h e i nt e r na l
a udi t o r y c a na l , wh e r e t h e b o ny pl a t e i s qui t e t h i n.
T h e f aci al ne r v e a l s o c a n b e i nj ur e d. To c o mp e t e ' h e
pr o c e dur e , dr i l l t h e p r o mo n t o r y a nd j o i n Ki e ova l
a n d r o t i nd wi n d o ws , e x p o s i n g t h e be gi nni ng o f t h e
ba s a l t ur n o f t h e c o c h l e a ( Fi g. 5 - 3 3 C) . Addi t i o na l
dr i l l i ng c a n be d o n e a t t h i s poi nt for pur po s e s o f
o r i e nt a t i o n t o t h e c o c h l e a r a n a t o my . P l a c i ng a a e l e c -
t r o de via t h e ba s a l t ur n c a n gi ve t h e s ur g e o n a : l e a r e r
g r a s p o f t h i s pr o c e dur e a nd its a n a t o mi c l o c a l o n.
At t hi s po i nt , a n i ns i de - o ut mo di f i e d r adi ca' . ma s -
t o i de c t o my ( a t t i c o t o my ) c a n be pe r f o r me d, , s de -
s c r i b e d e a r l i e r i n t h i s c h a pt e r .
Af t e r t h i s pr o c e dur e , i t wi l l be po s s i b l e t o r e pe a t
s o me o f t h e o pe r a t i v e pr o c e dur e s do ne wi t h t h e first
we t b o n e . F o r t h e ne x t pr o c e dur e s t wo we t b o n e s
a r e r e c o mme n d e d : o n e f or t h e mi ddl e f os s a a ppr o a c h
a nd o ne f or t h e r e ma i ni ng a ppr o a c h e s .
Retrolabyrinthine Approach to
the Cerebellopontine Angle
Aim
To o bt a i n s ur gi c a l a c c e s s t o t h e c e r e b e l l o po nt i ne
a ng l e a nd pr e s e r v e i nt e gr i t y o f t h e l a by r i nt h .
Highlights
1. Co mp l e t e r e mo v a l of b o n e up t o t h e po s t e r i o r
s e mi c i r c ul a r c a na l .
2 . S ke l e t o ni z a t i o n a nd mo b i l i za t i o n o f t h e s i gr o i d
s i nus t o a l l o w po s t e r i o r r e t r a c t i o n.
3 . Co mp l e t e r e mo v a l o f b o ne f r om t he p o s t c t c i
f os s a dur a , s i no dur a l a ngl e , a nd po s t e r i o r portio> t f
t h e t e gme n.
4. Re mo v a l of b o n e o v e r t h e po s t e r i o r f os s a d ira
po s t e r i o r t o t h e s i gmo i d s i nus .
Be f o r e b e g i nni ng t hi s a ppr o a c h , a s ma l l s e g m nt
o t I V t ubi ng o r r e d r ub b e r c a t h e t e r s h o ul d be pl a t e d
i n t h e i nt e r na l a udi t o r y c a na l t o s i mul a t e c r a r i.il
ne r v e s VII a nd VI I I . Bo n e wa x or gl ue wi l l h o l d i t i n
po s i t i o n.
Surgical Procedures
FIGURE 5- W
s ur gi c a l P r o c e dur e s
S ur gi c a l P r o c e dur e s 85
Horizontal canal
ampule
Common crus
Procedure
T h e i ni t i al s t e p i n t h e r e t r o l a b y r i nt h i ne a ppr o a c h
i s a t h o r o ugh s i mpl e ma s t o i d e c t o my a s de s c r i b e d
e a r l i e r i n t hi s c h a pt e r . Cl e a r i de nt i f i c a t i on of t h e
po s t e r i o r s e mi c i r c ul a r c a na l i s e s s e nt i a l , a s t h i s i s t h e
a nt e r i o r l i mi t o f t h e di s s e c t i o n a n d e x po s ur e . He nc e ,
i t i s i mpo r t a nt t o r e mo v e b o n e up t o t h e c a na l .
Ex p o s u r e a l s o i s e n h a n c e d b y a de qua t e r e mo v a l o f
b o n e i n t h e i nf r a l a b y r i nt h i ne cel l t r a c t . T h e s i gmo i d
s i nus i s s ke l e t o ni z e d a n d mo b i l i z e d, i f t h i s h a s not
a l r e a dy b e e n c o mp l e t e d . T h e a ut h o r s pr e f e r t o l e a ve
a n i s l a nd o f b o n e o n t h e s i nus ( Bi l l ' s i s l a nd) t o pr o t e c t
i t f r o m a c c i de nt a l r upt ur e wi t h a s h a f t of t h e b ur or
dur i ng r e t r a c t i on; b o n e c a n b e c o mpl e t e l y r e mo v e d
f r o m t h e s i nus i f s o de s i r e d. Bo n e c a n b e e i t h e r
c o mp l e t e l y r e mo v e d wi t h t h e d i a mo n d dr i l l o r
t h i nne d t o e ggs h e l l t h i c kne s s a nd r e mo v e d wi t h a
b l unt i ns t r ume nt .
F o l l o wi ng mo b i l i z a t i o n o f t h e s i g mo i d s i nus , t h e
b o n e e v e r t h e po s t e r i o r f os s a dur a a n d s i no dur a l
a ngl e ir- r e mo v e d i n t h e s a me wa y . Dur a i s ve r y
f r agi l e i n pr e pa r e d b o n e , a nd c a r e mus t be t a ke n no t
t o t e a r it. I t i s i mpo r t a nt t o r e me mb e r t h a t t h e
s upe r i o r pe t r o s a l s i nus r uns i n t h e s i no dur a l a ng l e ;
b l e e di ng i n t h i s a r e a mus t b e pr e v e nt e d. R e mo v a l o f
b o n e i s c o nt i nue d up t o t h e po s t e r i o r s e mi c i r c ul a r
c a na l . Ex po s ur e i s e n h a n c e d wi t h b o ne r e mo v a l c o n-
t i nue d a s h o r t di s t a nc e i nt o t h e t e g me n .
I t s h o ul d be r e me mb e r e d t ha t t h e po s t e r i o r f os s a
dur a mu s t a l s o b e e x po s e d po s t e r i o r t o t h e s i g mo i d
86 Surgical Procedures
Surgical Procedures 87
sinus to allow for better retraction. This is usually
not possible in temporal bone specimens, as this
bone is needed to hold bone in position.
Following decompression of the dura and sinus,
the dura is opened with a sickle knife and Malis
scissors. The incision lines are depicted in Figure 5-
34/1. The lateral incision parallels the sigmoid sinus,
running from superior to inferior, and runs just
lateral to the endolymphatic sac in its inferior aspect.
The second incision runs from lateral to medial and
parallels the superior petrosal sinus. The dura is
hinged at the posterior semicircular canal; the dura
flap is draped over the canal. With retraction of the
cerebellum (not present in specimen) and angling of
the microscope anteriorly, good visualization of the
cerebellopontine angle and cranial nerves V, VII,
VIII, IX, X, and XI is afforded (Fig. 5- 3 4B). For this
demonstration, identification of the internal auditory
canal marker should be accomplished.
Translabyrinthine Approach to
the Internal Auditory Canal
Aim
To expose and open the internal auditory canal
and identify the four cranial nerves contained within.
Higliliglits
1. Complete mastoidectomy and labyrinthectomy.
2. Identifying and outlining the internal auditorv
canal.
3. Opening into the internal auditorv canal; iden-
tifying Bill's bar and the transverse crest.
4. Identifying the superior and inferior vestibular
nerves, the cochlear nerve, and the facial nerve.
Procedure
The initial step in the translabyrinthine approach
is the complete mastoidectomy and labyrinthectomy
(described earlier). To help in later identification of
the superior vestibular nerve, the medial wall of the
ampulla of the semicircular canal is often preserved.
It is helpful to visualize the internal auditory canal
as it traverses the temporal bone.
Several points should be remembered. The inter-
nal auditory canal, as it runs anterior to posterior,
starts away from the dissection; hence, at the poste-
rior fossa dura it will be deeper or more medial than
at the vestibule. There is a common wall between
the vestibule and internal auditory canal. In other
words, the medial wall of the vestibule represents
the lateral wall of the internal auditory canal. A
reference for the direction in which the canal runs is
from the external genu to the sinodural angle.
Bone removal is continued medially following the
labyrinthectomy. Again, it is important to remember
that the canal becomes more medial (or deeper) as it
approaches the posterior fossa dura. As the canal is
approached a dark blue color will be seen, as in the
blue lining of any hollow structure. Diamond burs
are used at this point to decrease the risk of damage
to important structures. It is important to skeletonize
the internal auditory canal 180 degrees to allow
adequate exposure and prevent bony overhangs.
Superiorly, the middle fossa dura is identified and
followed medially. A thin layer of bone is left over
the internal auditory canal. The "trench" that is
developed extends from the facial nerve anteriorly to
the posterior fossa dura posteriorly. It is important
to remember that the superior petrosal sinus runs
posterior superiorly in the sinodural angle; careful
bone removal is required here. The inferior border
of the internal auditory canal is now delineated. It is
extremely important to be aware of and alert for the
jugular bulb as soon as the posterior semicircular
canal is removed in the labyrinthectomy. While usu-
ally positioned low in the mastoid tip, the bulb may
present as high as the posterior semicircular canal
(Fig. 5-35/1). Again, the internal auditory canal has
a blue lining, and a trench is developed inferior to
the canal. The inferior margin of this canal will be
the jugular bulb. It is safest to begin at the posterior
fossa junction and proceed medially and anteriorly.
As the incision continues anteriorly, a small white
discoloration in the bone will appear. This represents
the cochlear aqueduct, which is an important land-
mark. Extreme diligence is needed to identify this
structure. Cerebrospinal fluid often is released when
the aqueduct is entered. Anterior to this lie cranial
nerves IX, X, .and XI. Again, bone should be removed
for 180 degrees around the internal auditory canal.
The bone overlying the canal is thinned to eggshell
thickness; it can then be carefully cracked with a
blunt instrument and removed in one piece. The
dura is best opened inferiorly to protect the facial
nerve.
S ur gi c a l P r o c e dur e s
FIGURE 5-35.
90 S ur gi c a l P r o c e dur e s
To l o c a t e t h e v a r i o us ne r v e s i n t h e i nt e r na l a udi -
t or y c a na l , t h e f aci al ne r v e mus t first be i de nt i f i e d a s
i t r uns t h r o ug h i t s l a b y r i nt h i ne c o ur s e ( Fi g. 5 - 3 5 B ) .
Wi t h t h e us e o f s ma l l d i a mo n d b ur s , t h e f aci al ne r v e
c a n be s ke l e t o ni z e d ( b l ue - l i ne d) f r o m t h e a r e a o f t h e
s upe r i o r s e mi c i r c ul a r c a na l a mpul l a t o t h e first g e nu.
Aga i n, a t r e nc h c a n be de v e l o pe d b e t we e n t h e ne r v e
a nd t e g me n . T h e s upe r i o r s e mi c i r c ul a r c a na l a mpul l a
h e l ps t o i de nt i f y t h e s upe r i o r v e s t i b ul a r ne r ve ; its
me di a l wa l l r e pr e s e nt s t h e l as t r e ma i ni ng b o n e o v e r
t h e s upe r i o r ve s t i bul a r ne r v e a t i t s t e r mi na t i o n i n t h e
a mpul l a . Upo n r e mo v a l o f t h i s b o ne , t h e s upe r i o r
ve s t i bul a r ne r v e i s i de nt i f i e d. A 1- mm h o o k c a n be
us e d t o pe r f o r a t e Bi l l ' s ba r , wh i c h i s t h e r i dge of
b o n e s e pa r a t i ng t h e f aci al a nd s upe r i o r ve s t i bul a r
ne r v e s . To pr e v e nt d a ma g e t o t h e f aci al ne r v e , t h e
h o o k s h o ul d ne v e r b e i ns e r t e d i nt o t h e f a l l opi a n
c a na l . T h e s upe r i o r v e s t i b ul a r ne r v e i s t h e n a v ul s e d
( Fi g. 5 - 3 6 A) . Af t e r pr o pe r i de nt i f i c a t i o n o f Bi l l ' s ba r ,
i t i s s a f e t o r e mo v e e v e r y t h i ng l a t e r a l t o t h i s r i dge of
b o n e .
Ne x t , t h e t r a ns v e r s e c r e s t s h o ul d be i de nt i f i e d. A
b o n y p r o mi n e n c e t h a t l i es i nf e r i or t o t h e s upe r i o r
v e s t i b ul a r a nd facial ne r v e s , i t di vi de s t h e i nt e r na l
a udi t o r v c a na l i nt o s upe r i o r a nd i nf e r i or po r t i o ns .
I mme di a t e l y i nf e r i or t o t h e t r a ns v e r s e c r e s t i s t h e
i nf e r i or v e s t i b ul a r ne r v e . Me di a l t o t h i s l i es t h e c o c h -
l e a r ne r v e ( Fi g. 5 - 3 6 6 ) . Th i s c o mp l e t e s t h e e x p o s u r e
a nd i de nt i f i c a t i o n o f t h e i nt e r na l a udi t o r v c a na l .
Transcochlear Approach to the
Skull Bone
Aim
To ga i n a c c e s s t o t h e c e r e b e l l o po nt i ne a ng l e me di a l
t o t h e po r us a c us t i c us a nd/ o r a nt e r i o r t o t h e br a i n-
s t e m. Ac c e s s t o t h i s a r e a i s l i mi t e d wi t h a c o nv e n-
t i ona l s ub o c c i pi t a l a ppr o a c h b y t h e c e r e b e l l um a n d
b r a i ns t e m; i n t h e t r a ns l a b y r i nt h i ne a ppr o a c h i t i s
l i mi t e d by t h e f aci al ne r v e i n t h e t y mp a n u m a nd
ma s t o i d.
Highlights
1. Co mp l e t e ma s t o i d e c t o my a n d l a b v r i nt h e c t o mv .
2. Mo b i l i za t i o n o f t h e f aci al ne r v e wi t h i n t h e e nt i r e
f a l l opi a n c a na l .
3. Tr a ns po s i t i o n o f t h e f aci al ne r v e pos t e r i or
1
", .
4. Re mo v a l o f t h e f a l l opi a n c a na l a t al l t ur ns o f
t h e c o c h l e a .
5. Ant e r i o r l i mi t b e c o me s t h e i nt e r na l car ot i c. ar -
t e r y.
Procedure
T h e t r a ns c o c h l e a r a ppr o a c h i s a n a nt e r i o r e ; l e- i -
s i o n o f t h e t r a ns l a b y r i nt h i ne a ppr o a c h t o t h e e t e -
b e l l o po nt i ne a ngl e . Aga i n, t h e i ni t i al s t e ps a e a
c o mp l e t e ma s t o i d e c t o my a nd l a b y r i nt h e c t o my a s
de s c r i b e d e a r l i e r . T h e i nt e r na l a udi t o r y c a na l i s t h e n
o ut l i ne d, a nd t h e f aci al ne r v e i s i de nt i f i e d a s i t e nt e r s
t h e l a b y r i nt h i ne s e g me n t o f t h e f a l l opi a n c a na l . Thi s
i s f o und b y us i ng t h e a mpul l a o f t h e s upe r i o r s e mi -
c i r c ul a r c a na l as a l a ndma r k f or t h e s upe r i o r ve< fib-
ul a r ne r v e . Wi t h a s ma l l d i a mo n d bur , t h e t e g me a i s
f o l l o we d me di a l l y i n t h i s a r e a t o de v e l o p t h e s upe i o r
a s pe c t o f t h e i nt e r na l a udi t o r y c a na l . T h e f aci al ne r v e
wi l l be b l ue - l i ne d a s i t l e a v e s t h e i nt e r na l audi t >ry
c a na l a nd b e g i ns i t s c o ur s e i n t h e l a b v r i nt h i ne ' I ' g-
me n t o f t he f a l l opi a n c a na l ( Fi g. 5 - 3 7 / 1 ) .
T h e ne x t s t e p i s t o c o mpl e t e l y s ke l e t o ni z e h e
f aci al ne r v e f r o m t h e s t y l o ma s t o i d f o r a me n t o h e
i nt e r na l a udi t o r y c a na l . An e x t e nde d f aci al r e c e s s
o p e n i n g i s ma d e ( Fi g. 5 - 3 7 B ) . Af t e r a de qua t e t h n-
ni ng of t h e po s t e r i o r e x t e r na l a udi t o r y c a na l , a c ut t ; i g
o r d i a mo n d b ur i s us e d t o e nl a r g e a n a r e a i mme d i -
a t e l y i nf e r or t o t h e f os s a i nc udi s a nd l at er al t o 1 \ e
t aci al ne r v e a t t h e b e g i n n i n g o f i t s ma s t o i d s e g me t t .
It i s i mpo r t a nt t o us e as l a r ge a dr il l as po s s i b l e o
pr e v e nt t unne l i ng a nd po o r vi s ua l i za t i o n. I n a t r e
f aci al r e c e s s , c a r e mus t be t a ke n no t t o di s r upt t Ee
c h o r da t y mpa ni ( l a t e r a l l i mi t ) a nd t h e t v mpa ni c me m-
b r a ne . Th e s e s t r uc t ur e s wi l l be r e mo v e d i n t h i s
a ppr o a c h s o t h a t di s s e c t i o n ma v b e a c c o mpl i s h e d
mo r e s wi f t l v. Af t e r t h e o pe ni ng i s ma d e i nt o t h e
mi ddl e e a r , t h e i nc udo s t a pe di a l j o i nt i s vi s ua l i ze d
a n d s e pa r a t e d. T h e i nc us i s r e mo v e d t h r o ugh th!
a t t i c . T h e f aci al r e c e s s i s t h e n e nl a r ge d s u p e r i o r !
r
t h r o ugh t o t h e f os s a i nc udus a nd i nf e r i or l y t o t h '
l e ve l o f t h e f l oor o f t h e t y mp a n u m.
T h e e xt e r na l a udi t o r y c a na l i s t h e n r e mo v e d wi l l '
a r o ng e ur t o i mpr o v e vi s ua l i za t i o n of t h e f aci al ne r v e
T h e a nt e r i o r b ut t r e s s i s dr i l l e d t o t h e l e ve l of th' .
mi ddl e f os s a t e g me n a nd i nf e r i or l y a s a s mo o t l
t r a ns i t i o n t o t h e f l oor o f t h e t y mp a n u m i s a c c o m-
pl i s h e d. Wi t h t h e d i a mo n d dr i l l , t h e facial ne r v e
t h e n s ke l e t o ni z e d c o mpl e t e l y wi t h i n t h e t e mp o r e
b o n e . T h e c h o r d a t y mp a n i h a s a l r e a dy b e e n s acr i -
f i c e d. Wh e n t h e b o n e h a s b e e n c o mpl e t e l y r e mo v e d ,
S ur gi c a l P r o c e dur e s
FIGURE 5-36
92 Surgical Procedures
the greater superficial petrosal nerve is cut at its
origin from the geniculate ganglion (Fig. 5-37C). This
frees the facial nerve from all attachments in the
temporal bone. It is then carefully reflected poste-
riorly out of its bony bed.
Any remaining tympanic membrane is now re-
moved, as well as any skin remaining on the anterior
part of the external auditory canal. The anterior
external auditory canal and any bony overhang are
drilled to the level of the temporomandibular joint.
The stapes is also removed at this point. Starting
with the basal coil, the cochlea is completely drilled
out, as well as the remnant of the fallopian canal
(Fig. 5- 38B). (It is good practice to follow the coch-
lea's coils to gain a better understanding of its anat-
omy. ) Bone removal is carried forward to the septum
that lies between the internal carotid artery and
anterior wall of the basal coil. The internal carotid
artery can be blue-lined with the diamond drill, much
as the jugular bulb is blue-lined in the translabyrin-
thine approach. Interiorly, bone removal extends to
the inferior petrosal sinus and jugular bulb. Superi-
orly, the superior petrosal sinus and tegmen are
followed medially to Meckel's cave (Fig. 5- 3 8C).
Medially, removal of bone continues to the lateral
clivus. When bone removal has been completed, a
large window covered by dura ( bounded superiorly
by the superior petrosal sinus and interiorly by the
jugular bulb and inferior petrosal sinus, with its apex
just below Meckel's cave and the internal carotid
artery located anteriorly) is created into the skull
bone. If the dura is still intact, this window can be
opened posterior to the internal auditory canal and
extended as far forward as needed for exposure.
Cuts may run medially, anteriorly, and parallel to
the superior petrosal sinus and jugular bulb.
In an actual procedure, the dural defect is packed
with abdominal fat and the external ear canal is sewn
shut to prevent postoperative leakage of cerebrospi-
nal fluid.
Middle Fossa Approach to the
Internal Auditory Canal
Aim
To expose the floor of the middle cranial fossa and
identify the structures contained within, including
the cochlea, arcuate eminence, and contents of the
internal auditory canal.
Surgical Procedures 93
Procedure
When practicing this approach in the laboratory,
placement of the bone within the bone cup is impor-
tant. Imagine a patient lying supine with the head
turned to one side; the surgeon sits at the head of
the patient and looks down on the middle cranial
fossa floor through the craniotomy opening (de-
scribed earlier). Hence, the bone needs to be placed
in the bone cup so that the surgeon looks directly
down upon the floor of the middle fossa (Fig. 5-
39/ 1). If the dura is still intact, it should be stripped
from the exposed floor. As the dura is being elevated,
the middle meningeal artery will be found anteriorly
as it exits from the foramen spinosum. This repre-
sents the anterior limit of an adequate exposure.
After all the dura has been removed, the floor should
be studied. Laterally, where the floor rises to the
pars squamosa, the tegmen overlies the aerated mas-
toid and; the epi tympanum. The eustachian tube
( covered by thin bone) is located anterior to the
epi t ympi num. Posteriorly, the floor of the middle
fossa drops into the posterior fossa. Along this ridge
runs the superior petrosal sinus within the reflected
dura. Approximately" 1 cm medial to the middle
meningeal artery lies the greater superficial petrosal
nerve, which runs in a posterior to anterior direction
as it leaves the geniculate ganglion. This nerve is an
important landmark; it can be followed back to find
the geniculate ganglion and the facial nerve. In
approximately 5% of cases the geniculate ganglion
will not be covered by bone. Another important
landmark is the arcuate eminence of the superior
semicircular canal; usually an obvious feature, it may
occasionally be indistinct. It is medial to the aerated
bone of the mastoid and epitympanum, and appears
as a rounded prominence. It must be remembered
that every temporal bone will have its own unique
middle fossa topography; no consistent landmark
Highlights
1. To decompress the labyrinthine segment of the
facial nerve or remove facial nerve lesions.
2. To remove small intracanalicular acoustic tu-
mors in art attempt to preserve residual hearing.
3. To rupair large defects of the tegmen and dura
that have Resulted in cerebrospinal fluid leaks.
4. To section the superior and inferior vestibular
nerves and retain hearing.
Surgical Procedures
FIGURE 5-38.
Surgical Procedures
FIGURE 5-39.
96 Surgical Procedures
Incus
| Facial nerve
In' vestibular nerve
FIGURE 5-10 .
Surgical Procedures 97
can be relied upon. Familiarity with the middle fossa
is accomplished only with repeated inspection and
dissection. The major landmarks of the middle fossa
have now been identified, including the middle me-
ningeal artery, the greater superficial petrosal nerve
with its facial hiatus, and the arcuate eminence.
Dissection begins with positive identification of
the facial nerve. The greater superficial petrosal nerve
is followed back to the facial hiatus, where it enters
and joins the geniculate ganglion. With a large dia-
mond bur and suction irrigation to avoid heat gen-
eration and bone dust accumulation, the thin bone
overlying the geniculate ganglion is removed (Fig.
5- 39B). Here the facial nerve turns slightly posterior
and inferior as it runs into its tympanic course. The
epi tympanum may be opened to expose the head of
the malleus, tensor tympani, and cochleariform proc-
ess. The cochleariform process is the limit to which
the facial nerve can be adequately decompressed by
this, approach. Following this, the labyrinthine seg-
ment of the facial nerve is exposed; this is a very
short segment running from the geniculate ganglion
to the lateral end of the internal auditory canal. Care
must be taken not to enter the ampulla of the
semicircular canal, which lies only a few millimeters
posterior, or the cochlea, only a few millimeters
anterior. This segment of the facial nerve courses
almost parallel to the plane of the semicircular canal.
A di amond bur is needed to work in this limited
space. Bone is removed medially following the course
of the facial nerve, which runs in a posterior and
inferior ( deeper) direction. When the posterior fossa
is reached (medially), the exposure can be widened
because the semicircular canal courses posteriorly
and the dissection at this point is medial to the
cochlea. As the edge of the posterior fossa is reached,
remember that the superior petrosal sinus lies in this
dural reflection. At this point obtain wide exposure
of the internal auditory canal. By carefully removing
the final eggshell thinness of bone, the contents of
the canal may be identified. The facial nerve occupies
the anterosuperior compartment, with the superior
vestibular nerve immediately behind in the postero-
superior aspect (Fig. 5- 39C). At the lateral end of the
canal is Bill's bar, the ridge of bone separating these
two nerves. Here the superior vestibular nerve runs
to the ampulla of the semicircular canal. Immediately
below the facial nerve lies the cochlear nerve, and
the inferior vestibular nerve lies beneath the superior
vestibular nerve. These represent the anteroinferior
and posteroinferior compartments respectively.
For the sake of completeness, the following struc-
tures should be found and followed in their courses.
This will help to further the understanding of tem-
poral bone anatomy in a three-dimensional view (Fig.
5- 40 ) . Slightly lateral to the greater superior petrosal,
the eustachian tube runs medially from the middle
ear cavity to the nasopharynx. Upon dissection of
the eustachian tube, the carotid artery may be found
on the inferomedial floor of the tube; it courses
horizontally from the middle ear to the cavernous
sinus. The semicircular canal and cochlea should be
entered and followed to gain a clear understanding
of their positions within the temporal bone.
SECTION III
i
General Principles
and Approaches
CHAPTER 6
Operating
Room Principles and
General Concepts
Evaluation
All patients should have a complete history ob-
tained and be given a physical examination. Al-
though proper surgical indications and adequate lab-
oratory studies are essential, their discussion is
beyond the scope of this chapter. A complete assess-
ment of the patient's general conditions, as well as
of the otologic problem itself, is to be made. It should
be remembered that the ear is not an isolated organ;
it interrelates anatomically and functionally with
other organs and systemsfor example, the naso-
pharynx and nasal cavitythat must be evaluated in
detail. The local conditions of the ear, including the
skin of the pinna, the ear canal, middle ear mucosa,
and so forth, must be improved as much as possible
before surgery.
An otologic evaluation includes a number of basic
tests in addition to the history and physical exami-
nation. A recent complete audiogram that includes
pure tones and speech discrimination is essential.
Equally important is confirmation of the results by
the surgeon, utilizing tuning forks.
Radiologic studies include conventional mastoid
x-rays supported by tomograms, computed tomo-
graphic scans, magnetic resonance, and other imag-
ing modalities, depending on specific needs such as
in cases of retrocochlear lesions, complications of
otitis media, and congenital atresia. Specific indica-
tions of such studies will not be discussed here except
to mention that conventional x-rays remain valuable
and essential in many cases, providing information
on mastoid aeration, the position of the sigmoid
sinus, anc other details. X-rays must be available in
the operaf ng room. A number of additional tests are
used, su< "i as BAER (brainstem auditory evoked
responses;, electrocochleography, promontory stim-
ulation, and others, the indications for which are
outside the scope of this atlas. The essential concept
in this section is that the patient must be evaluated
from a general as well as a local standpoint, and that
tests serve the purpose of screening, ruling out, or
confirming specific questions in the mind of the
surgeon. They are not a "routine blanket ordered
according to trends," nor are they intended to replace
common sense and clinical acuity.
Patient Consent
As important as informed consent is from a legal
standpoint, it is much more important in that it
provides the patient with information. It is essential
that the patient (or his or her parents) be aware of
the rationale for and purpose of the surgical proce-
dure. Is tlje aim reconstruction of the ossicular chain?
Is it eradication of disease? What are the chances of
success and the risks involved?
A well-informed patient is the best guarantee of
success. I.iformation on the postoperative course and
care is also essential and should be provided by the
surgeon. Commercially printed instructions are very
10 2 Operating Room Principles and General Concepts
helpful; however, they do not approach the useful-
ness of instructions printed by the surgeon.
Anesthesia
Most otologic procedures can be performed under
local anesthesia, with or without sedation. The de-
cision will depend on the specific case and the
surgeon's judgment and common sense. It should
be remembered that a general anesthetic usually
carries a small risk, at times comparable with that of
local procedures under sedation. If a local anesthetic
is to be used, it is important to know the innervation
of the area to be anesthetized. (See the chapters on
anatomy and general surgical approaches. ) Different
agents are utilized; the authors usually use lidocaine
(Xylocaine) 1% with 1:10 0 ,0 0 0 epinephrine in both
local and general anesthesia cases, since epinephrine
exerts a vasoconstrictive effect essential for micro-
scopic surgery. The maxi mum safe dose of lidocaine
is 3 mg/kg without epinephrine and 7 mg/kg with
epinephrine. In cases of myringotomies and tubes,
iontophoretic anesthesia is a useful method in the
office. It is based on a battery-operated unit (ionto-
phoretic applicator) that generates a constant direct
current, allowing ion transfer of a local anesthetic
(placed in the ear canal) into the ear canal and
tympanic membranes. Because it does not require an
injection it is verv well accepted by some patients.
Antibiotics
The use of antibiotics is a controversial abj ect
that will not be dwelled upon here. The aut hor; use
them prophylactically when there is a risk that nf ei -
tion will extend into the inner ear or intracrajiially,
compromi se the survival of a graft or reconstructive
procedure, or spread locallyfor example, 6 ths
auricular cartilage. When antibiotics are used; it is
immediately before, during, and after the operation.
In chronically draining ears the authors tend to star'
antibiotic therapy several days prior to the procedure
Use of antibiotics does not mean that strict aseptic
techniques are disregarded; they are used only when
there are additional risks in spite of a flawless .ech-
nique that includes asepsis, meticulous hemoslasis,
and gentleness with tissues.
Equipment and Procedures
The operating table must be comfortable but dard
enough to allow for resuscitation procedure; if
needed. It should be easily adjustable so that it can
be raised or lowered or the patient placed in a
Trendelenburg or reverse Trendelenburg position
(Figs, 6 - 1, 6 - 2). The headpiece should be separable
in order to change the position of the patient's head
independently from the rest of the table (Fig. f-3).
Operating Room Principles and General Concepts
FIGURE 6 -2.
At times a simple "donut" will suffice; in general,
however, a Juers head holder is more useful, allow-
ing adjustments in angulation of the head as needed
(Figs. 6 - 4, 6 - 5). The patient's head should be taped
to the head holder (which in turn is taped to the
head of the table) and moved with the holder as a
unit (Fig. 6 - 6 ) . The patient lies supine with the head
turned and lowered in order to bring the external
auditorv canal, which has a bonv orientation that is
downward and forward, into a nearly vertical posi-
tion.
Preparation of the Skin
The skin is prepared after shaving the hair. Shav-
ing of the hair is done with a dry razor blade at the
time of surgery, avoiding any lacerations of the skin.
Enough ,:air is shaved to provide a clean operative
field For i postauricular approach the authors shave
an area of approximately 2. 5 cm. If a large flap is to
be raisec. (for example, for a postauricular cochlear
i mplant)'more hair is shaved. For an endaural ap-
F1GURE 6 -3.
A headpiece that can be separated
from the table is useful.
10 4 Ope r at i ng Ro o m Pr i nci pl es a nd Ge ne r al Co nc e pt s
FIGURES 6 -4, 6 -5.
A Jucrs head holder allows
neuverahilitv.
pr o a c h 0 . 5 cm o f hai r s uper i o r l y al o ng t he s uper i o r
hel i x will suf f i ce. A ger mi ci dal s o ap and s ol ut i on
s u c h as po vi do ne- i o di ne ( Bet adi ne) o r he xac hl o r o -
phe ne ( pH i s o H e x ) i s us ed. Whi c he v e r ag e nt i s s e-
l ect ed, t he s cr ub s ho ul d be f or t en mi nut e s and t he
s ol ut i on wi pe d d r y bef or e st eri l e d r ape s ar e appl i ed.
The ear canal i s cl eans ed wi t h a s ol ut i on s uch as
hyd r o g e n pe r o xi d e o r i r r i gat ed wi t h s al i ne, o r bot h.
The o per at i ve field i s i s ol at ed wi t h st eri l e d r ape s ,
avo i di ng exces s i ve bul k t hat wo ul d c o mpr o mi s e mo -
bi li ty. The "hang i ng d r a pe s " ar e c l ampe d t o g et h ;
i n o r d e r t o al l ow t he s ur g e o n' s l egs t o fit c o mf o r t ah
:
)
u nd e r t he head o f t he t abl e wi t ho ut i nt er f er ence.
Foreign Body Reaction
Par t i cl es c o nt ai ne d i n gl o ves ( po wd e r ) , a pro: ;
t hes i s , o r s ur gi cal i ns t r ume nt s can c aus e i nf l amma
Ope r at i ng Ro o m Pr i nci pl es and Ge ne r al Co nc e pt s 10 5
FIGURE 6 -6 .
The patient's head is taped to the
head holder.
t o r y r eact i o ns t hat ar e pot ent i al l y har mf ul . It i s a
g o o d habi t t o ke e p a st eri l e s ol ut i on and a mo i s t
t o wel t o ri ns e and cl ean t he s ur gi cal gl o ves bef or e
i ni t i at i ng s ur g er y. The s cr ub nur s e s ho ul d have o n
hi s or he r t abl e a c o nt ai ne r wi t h s al i ne i n o r d e r t o
cl ean t he i ns t r u me nt s and pr o s t hes i s pr i or t o us e.
I ns t r u me nt s s ho ul d be r i ns ed met i cul o us l y af t er t he
us e o f st eri l i zi ng chemi cal s , s i nce t hes e c an be ve r y
d a ma g i ng t o t i s s ues .
Positioning of the Surgical Team
The surgeon mu s t be i n a c o mf o r t abl e and s t abl e
pos i t i on, wi t h bo t h f eet on t he f l oor, and wi t h t he
back s u ppo r t e d by a chai r t hat can be mo v e d eas i l y
( by t he s ur g e o n) whi l e r et ai ni ng i ts pos i t i on. The
pat i ent mu s t be pl aced s o t hat t he s u r g e o n i s not
bent or f or ced i nt o unc o mf o r t abl e pos i t i ons . Thi s i s
us ual l y achi eved by pos i t i oni ng t he he ad of t he
o pe r at i ng t abl e vi r t ual l y o ve r t he s ur g e o n' s l ap, wi t h
t he s u r g e o n capabl e of "co mf o r t abl y wr i t i ng on a
d e s k" whi l e l ooki ng t hr o u g h t he mi c r o s c o pe .
The surgical team i s of t he ut mo s t i mpo r t anc e . A
s ucces s f ul s urgi cal pr o c e d u r e r e pr e s e nt s t he c o m-
bi ned ef f ort s of a t e am of s u r g e o ns , anes t hes i o l o gi s t s ,
and s c r u b and ci r cul at i ng nur s es . No mat t e r ho w
ski l l ed t he s ur g e o n, hi s or her wo r k i s not pos s i bl e
wi t ho u t a saf el y a nd adequat el y ane s t he t i z e d or
s e d at e d pat i ent ; no ma t t e r ho w ski l l ed t he ane s t he -
si ol ogi st , ad e q u at e anes t hes i a will no t be pos s i bl e i f
t he s u r g e o n d o e s no t i nf o r m hi m o r her o f t he
mo me n t of i nj ect i on of e pi ne phr i ne , mobi l i z at i on of
t he he ad o f t he pat i ent , el evat i o n o f t he o per at i ve
t abl e, o r o t he r pr o c e d u r e s . The s a me r ul es appl y i n
pr i nci pl e f or t he ci r cul at i ng and s cr ub nur s es . The
pr e c e pt of t hi s c hapt e r i s t hat i n s ur g e r y, t e a mwo r k
yi el ds bet t er r es ul t s t han " wo nd e r ma n " o r " wo nd e r
wo ma n " al o ne.
The au t ho r s ' pos i t i oni ng o f t he t eam and i ns t r u-
me nt s i n t i e o per at i ng r o o m i s s ho wn i n Fi g ur e 6 -
7. The s c r u b nur s e i s at t he ri ght of t he s u r g e o n a nd
t he as s i s t ant i s at t he left. Ot he r s u r g e o ns pr ef er
di f f erent s e t ups . The bes t pos i t i on i s o ne t hat pr o -
vi des t he i i o s t c o mf o r t and ef f i ci ency t o a par t i cul ar
t e am.
Instruments
The operating microscope o bvi o us l y mu s t be bi noc-
ul ar wi t h a f ocal l engt h of at l eas t 20 c m. The au t ho r s
pr ef er t o us e t he 2 5 - cm l engt h; i t pr o vi des a r ang e of
magni f i cat i o n f r o m 6 X to 40 X , wi t h 6 x , 10 x , a nd
1 6 X t he mo s t c o mmo n l y us ed. Al o ng wi t h g o o d
l i ght ( ei t her bul b or f i beropt i c) , i t r equi r es g o o d
handl i ng abi l i t y. Bo t h t he s u r g e o n and t he s cr ub
nu r s e mu s t be f ami l i ar wi t h t he di f f erent kno bs t hat
pr o vi de maneuver abi l i t y. The au t ho r s pr ef er t o us e
an ang l e d eyepi ece t hat pr o vi d e s an ang l e o f 4 5
d e g r e e s a nd al l ows a mo r e co mf o r t abl e he ad pos i t i on
for t he s u r g e o n ( Fi g. 6 - 8 ) .
Operating Room Principles and General Concepts 10 7
urnmiit
I
I
FIGURE 6 -8.
The eyepiece angles (IF A microscope.
In spite of the many theoretical advantages of fully
automated microscopes (except for their price), the
classic Zeiss OPM1-1 or one of its equivalents (for
example, Vasconcellos) allows better maneuverability
and is less cumbersome to operate in ear surgery.
Again, this is a matter of preference; the point is
made because it is not unusual for the "starting
surgeon in practice" to be talked into buying a fully
automated, "state of the art" piece of equipment.
The position of the microscope is essential. The
arms should be at a 90 -degree angle, which permits
a full range of motion (Figs. 6 -9, 6 -10 ). In the case
of the OPM1-1 the "longer leg" of the pedestal should
point toward the patient's shoulder on the operated
side. The side viewer (teaching lens) is placed at the
left side; if possible a video camera is attached. This
allows the operating team to be aware of the proce-
dure, anticipate the use of instruments, and even
maintain a permanent record of the operation. A
suitable sterile drape of either cloth or disposable
plastic must be used (Fig. 6 - 11). For insertion of PE
tubes, rubber handles for focusing and magnification
are useful. If they are not available, a sterile towel
will suffice.
A variety of drills are commercially available. A
high-speed drill should suffice, provided that it is a
durable instrument capable of withstanding contin-
uous use. At least two drills should be available in
the operating room. The drill handles should be light
and easy to manipulate; the instrument should have
several speeds, including reverse and forward. Con-
trol by a foot pedal is preferable since handle-con-
trolled drills tend to have more vibration. The reverse
speed is useful for saucerizing small bleeding points
in the mastoid and bony ear canal. It is also important
that both the surgeon and scrub nurse should be
able to assemble and operate the drill. Different metal
burs, usually made out of tungsten or steel, are
available. Rounded burs work best for otology; they
can be of six or eight teeth. In general, burs with
more teeth accumulate more debris and are less
effective; however, a bur full of debris is useful in
areas requiring gentle work, and is similar in this
regard to a diamond bur (a metal bur coated with
diamond powder). Burs must be sharp; dulling leads
to overheating. The authors favor burs with regular
shafts over those with special hooks, which in prac-
tice limit ;(he surgeon to particular brands; the more
universal the drill, the better. Sizes of burs vary
according'to need (discussed in specific chapters).
The "suction irrigation" feature is commonly used
today. Drills with continuous irrigation (variable
flow) are available, and are useful in avoiding drilling
over "dry bone," which promotes overheating and
necrosis. The authors prefer to use intermittent irri-
gation with a bulb syringe to provide moisture as
needed, thus avoiding the visual distortion that oc-
curs with "underwater drilling." Again, the purpose
is to avoid heating and necrosis of bone; that is best
achieved in a manner that is efficient for the surgeon.
Good suction is essential. The tubing should be
flexible, soft but not collapsible, and not too rigid,
so that it is easy to handle. A No. 5 suction tip is
used for cleansing the ear canal, a No. 20 for raising
flaps and for middle ear work, and a No. 24 for work
in the oval window. The authors prefer fenestrated
Ope r a t i ng R o o m P r i nc i pl e s a nd Ge ne r a l Co n c e p t s 10 9
FIGURE 6 -11.
A disposable sterile plastic drape has
been used with this microscope,
which has a video camera attached.
h a ndl e s , wh i c h a l l o w c o nt r o l o f t h e de g r e e o f s uc t i o n;
s o me s ur ge o ns pr e f e r t o c o nt r o l t h e de g r e e o f s uc t i o n
wi t h a f oot c o nt r o l . Fo r dr i l l i ng, l a r ge r s uc t i o n t i ps
ar e us e d ( No . 7 t o No . 9 F r e nc h ) . A s y r i nge f or f o r c e d
i r r i gat i on, as wel l as a wi r e t o c l e a n t h e s uc t i o n t i p,
s h o ul d be a va i l a bl e . S ma l l s p o n g e s o r c o t t o n ba l l s
s h o ul d b e us e d a t t h e s uc t i o n t i p wh e n wo r ki ng o v e r
gr af t s o r pr o s t h e s e s t ha t c a n be l o o s e ne d o r di s l o dge d
by t h e s uc t i o n. ( Co t t o n mus t no t be l eft i n t h e e a r
s i nc e i t i s a g ua r a nt e e of i nf e c t i o n. ) T h e a ut h o r s '
us ua l i ns t r ume nt s e t up i s s h o wn i n Fi gur e s 6 - 1 2 a nd
6 - 1 3 .
S t a nda r d c a ut e r y uni t s wi l l no t be de s c r i b e d; s uf -
f i ce i t t o me nt i o n t h a t t h e a ut h o r s r o ut i ne l y us e a
mo no po l a r uni t , but f or c a s e s o f a c o us t i c n e u r o ma
o r i n wh i c h wo r k i s t o be d o n e ne a r t h e f aci al ne r v e
a bi po l a r uni t s h o ul d be a va i l a bl e , b o t h t h e s uc t i o n
a nd c a ut e r y uni t s s h o ul d b e a de qua t e l y po s i t i o ne d
a nd c l i ppe d t o t h e dr a pe s , wi t h s uf f i c i e nt l e ngt h t o
a l l ow e a s y h a ndl i ng b ut s h o r t e n o u g h t o pr e v e nt
c o nt a mi na t i o n i f t h e uni t s a r e d r o p p e d ( Fi g. 6 - 1 4 ) .
A va r i e t y of i ns t r ume nt s e t s a r e c o mme r c i a l l y
a va i l a bl e . S i nc e t h e pur po s e o f t h i s a t l a s i s de s c r i pt i v e
a nd no t pr o mo t i o na l , t h e a ut h o r s ' s pe c i f i c pr e f e r -
e nc e s a r e no t l i s t e d; t h e y wi l l be s e nt u p o n r e que s t .
I t i s i mpo r t a nt t o a c qui r e qua l i t y i ns t r ume nt s , pa r t i c -
ul ar l y for wo r k i ns i de t h e e a r . Ap p a r e n t s a v i ngs f r om
buy i ng c h e a pe r but po o r l y ma d e i ns t r ume nt s c a n b e
i l l us or y. I ns t r ume nt s a r c de s i g ne d f or s pe c i f i c pur -
po s e s a nd s h o ul d be pur c h a s e d wi t h t h e m i n mi nd.
I ns t r ume nt s b e a r i ng t h e e n d o r s e me n t o f a pa r t i c ul a r
s ur g e o n pr o v i de a s e n s e o f s e c ur i t y a nd s h o ul d be
c o ns i de r e d f or a c qui s i t i o n; h o we v e r , t h e y r e pr e s e nt
t h e pr e f e r e nc e o f t ha t s ur g e o n a nd ma y no t ne c e s -
s a r i l y me e t y o ur ne e ds .
Operating room cards de s c r i b i ng t h e i ns t r ume nt s
a nd ma t e r i a l s r e qui r e d f or di f f e r e nt s ur gi c a l pr o c e -
dur e s s h o ul d b e a va i l a bl e . T h e y ma k e t h e nur s e s '
j o b s e a s i e r a nd mo r e e f f e c t i ve . Ea r i ns t r ume nt s pr ef -
e r a bl y a r e pl a c e d i n a r a c k a nd n u mb e r e d i n t h e
o r de r i n wh i c h t h e y a r e us e df o r e x a mpl e , No . 1
s t r a i gh t c a na l kni f e . No . 2 c ur v e d c a na l kni f e , No . 3
duc kbi l l e l e v a t o r , a nd s o o n. I f t h e s c r ub a nd c i r c u-
l a t i ng nur s e s r ot a t e o r t h e o pe r a t i ng r o o m " c o mmi t -
t e e " b e l i e v e s t h a t nur s e s c a n b e " j a c ks o f al l t r a de s , "
i t i s us e f ul t o pr i nt t h e n a me s of t h e i ns t r ume nt s
( b e s i de t hei r n u mb e r s ) a nd t o pl a c e on t h e t a bl e a
pl a s t i c i ze d, ' s t e r i l i za bl e " c a r d l i s t i ng t h e n a me s a nd
po s i t i o ns o f i ns t r ume nt s a nd ma t e r i a l s . I n a ddi t i o n,
c a r ds de s c r i b i ng t h e po s i t i o n o f t h e t e a m i n t h e
o pe r a t i ng r o o m s h o ul d be t a pe d t o t h e wa l l i n a
c l e a r l y v i s i b ' e pl a c e .
Record of Operation
As i mpo r t a nt a s de s c r i b i ng wh a t wa s d o n e i s
de s c r i b i ng wh a t wa s f o und, pr e f e r a bl v wi t h a dr a w-
Operating Room'Principles and General Concepts 111
ing. Problem areas should be noted; such records are
useful in evaluating prospective causes and factors
in both failures and successful results. A stamped or
printed drawing or diagram in the operative descrip-
tion is useful. Packing techniques are described in
specific sections and will not be discussed here.
Illustrations of how to apply an oval eye pad (Figs.
6 - 15 to 6 -17) and a mastoid dressing (Figs. 6 -18 to
6 -30 ) are included, as well as two photographs show-
ing the application of ointment with a rubber-tipped
syringe (Figs. 6 - 31, 6 -32).
FIGURE 6 -14.
Suction tip and cautery "hanging" in the operating field. They
are not left in this position during surgery; this figure simply
shows that if clipped correctly, the suction tip and cautery will
not become contaminated if they fall.
i
Surgical Time
$
It is i mpo r t ant to develop surgical techniques and
habits that fellow a systematic and efficient use of
time, but c o mpl e t e ne s s and thoroughness are equally
essential. In^ measuring success, results have more
weight than speed. Would you prefer to be operated
on by a s #geon who is rushing to "finish the
schedule" of by one who is more concerned about
finishing o nl y when his or her purposes of helping
you have be;?n surgically achieved?
I
FIGURES 6 -15 to 6 -17.
Placement of an ova] eye pad
Operating Room Principles and General Concepts
Operating Room Principles and General Concepts 113
114
Operating Room Principles and General Concepts
Operating Room Principles and General Concepts
115
FIGURE 6-20.
FIGURE 6-22.
FIGURE 6-21.
FIGURE 6-23.
- - - - - - - . - - - - - ~ - -
Operating Room Principles and General Concepts 117
118 Operating Room Principles and Genera! Concepts
Operating Roojn Principles and General Concepts 119
i
Operating Room Principles and General Concepts
F I GURE 6 - 3 2 .
CHAPTER 7
Surgical Approaches
to the External Ear Canal
and Middle Ear
This chapter describes basic general principles
underlying the possible alternative approaches to the
external ear canal and middle ear. It is obvious that
the approach selected will depend upon the type of
procedure planned, the needs of exposure, and the
surgeon's preference or ability. Specific approaches
are described in the chapters in Section IV; however,
since these basic principles apply partly or totally in
those approaches, they are described separately here
in order to avoid repetition.
Three alternative approaches are available to gain
access to the external ear canal and middle ear: the
transcanal, the endaural, and the postauricular (Fig.
7- 1) . In all three approaches, all surgical steps are
equally important and should be done methodically
and carefully, from preparing the patient, draping,
and positioning, to applying the last piece of tape to
the dressing. Meticulous care should be observed.
The procedure is not finished when the flaps are
repositioned; it is finished when the ear is healed.
All steps, including postoperative care, are essential
for proper healing.
Transcanal Approach
Highlights
1. Adequate visualization.
2. Completion of incisions (all the way through).
3. Elevation of an intact flap.
4. Entrance into the middle ear beneath the an-
nulus.
5. Meticulous anatomi c repositioning of the flap.
6 . Careful packing.
Pitfalls
1. Operating in a small space without visualiza-
tion.
2. Tearing the flap or tympanic membrane.
3. Suctioning the flap.
4. Making superficial incisions.
5. Entering the middle ear above the annulus.
6 . Selecting an inadequate approach.
Inspection and Cleansing
Once the patient has been adequately positioned
and the ear has been sterilely prepared and draped,
the canal and tympanic membrane are inspected with
an ear speculum. An oval, anteriorly beveled, non-
reflecting speculum of the largest possible size is
used. Too small a speculum provides inadequate
vision and is too loose; too large a speculum causes
folds in the ear canal that obstruct vision and macer-
ate the skin. The correct size allows satisfactory vision
and sufficient tightness to allow bimanual explora-
tion.
Surgical Approaches to the External Ear Canal and Middle Ear
Surgical Approaches to the External Ear Canal and Middle Ear 123
The narrowest portion of the external ear canal is
medial to the junction of the bony and cartilaginous
canal; it is at this point that placement of the spec-
ulum is critical. The canal is carefully cleansed with
ring curets, suction (No. 5), or both. The skin and
tympanic membrane are carefully visualized, and the
size of the canal is appreciated. This visualization is
very important, since the surgeon should first think
in terms of anatomy. Whatever needs to be done in
the middle ear is done best with adequate exposure.
Again, positioning of the patient and the surgeon
plus adequate angulation of the arm of the micro-
scope are essential. It is a good idea to gently irrigate
the canal (with either saline or alcohol).
Injection of Local Anesthetic
Injection of the anesthetic is a skill to be mastered
by all means. It is a crucial step that decides if the
procedure will be done in a clean, dry field or in a
field obstructed by blood and offering inadequate
vision. A local anesthetic with vasoconstrictor is
used, usually lidocaine 2% with 1:10 0 ,0 0 0 epineph-
rine. Alternative anesthetic agents (owing to aller-
gies, desire for a longer-lasting effect, or other rea-
sons) or different concentrations of epinephrine are
acceptable, but maxi mum doses must be kept in
mind in order to avoid toxicity or cardiovascular
effects, or both. A syringe affording ease of injection
(for example, Carpule) is preferred. A 27- or 30 -
gauge needle is used. A nasal speculum is used for
initial injections into the four quadrants of the carti-
laginous canal (Fig. 7-2A). The bevel of the needle
is placed parallel to the surface of the underlying
cartilage (or bone), and injection is done very slowly
in order to avoid blebs. (If a small bleb is formed, it
can be punctured with a needle.) With slow injection
under direct vision infiltration and blanching of the
skin can be clearly noted; thus the necessary amount
of anesthetic can be easily decided. With the aid of
an ear speculum, additional injections are done, if
needed, into the bony canal under direct vision until
blanching of the skin is observed. The skin of the
osseous canal is thinner than that of the cartilaginous
portion; it is usually simpler and safer to inject into
the cartilaginous portion, allowing the injected so-
lution to "dissect its way toward the annulus." On
occasion, under local anesthesia a facial paralysis
becomes evident at this point. This denotes a dehis-
cent facial nerve, which should completely recover.
Incisions
With the speculum tightly in the canal and the
surgeon working with two hands, the incisions are
made. A Paparella No. 1 straight canal knife or sickle
knife is used for the first incision at 12 o'clock in a
direction straight toward the surgeon (Fig. 7-2B). A
second incision is made at 6 o'clock, curving toward
the vertical incision; this curved incision can be made
with a curved canal knife. The length of the flap
(distally from the annulus to the horizontal incision)
may vary, as well as the location of the vertical
incision. In a routine stapedectomy a 6 -mm flap
should suffice, whereas in a more extensive explo-
ration with a small atticotomy, or if extensive bony
canal is to be removed, an 8-mm flap might be
necessary. If the canal is wide, a large flap extending
even to the cartilaginous canal can be used, since
folding it anteriorly will not obscure vision or result
in a tight space with no room to work. The length
of the flap is then determined by means of exposure
and size of the canal.
If attic disease or fixation of the head of the malleus
is suspected, a wider flap is elevated, and the vertical
incision is made at the 1 or 3 o'clock position in order
to provide a flap of sufficient size to cover the defect
easily. If more extensive surgery is anticipated, an
endaural incision is used. When making the incision,
the underlying bone should be "felt" with an instru-
ment, even to the point of producing a sound, to
make certain that the skin is completely sectioned.
The junction of the skin with the annulus, at 12 or 3
o'clock, is usually thicker and richer in connective
tissue. Complete sectioning of this area is very im-
portant; a Bellucci scissors is very helpful for this
purpose. No attempt to lift flaps or gain entrance
into the middle ear should be made until the incisions
are completed and the skin flaps are free.
Elevation of Flaps
With the skin edges free, the surgeon takes his or
her finger off the hole of the suction tube and holds
the speculum and suction in the left hand (for a
right-handed surgeon) (Fig. 7- 2C). This helpful tech-
nique is not difficult to master, and with an ade-
quately shed speculum obviates the need for a spec-
ulum holder. The latter is a useful instrument, the
most widely used design being the classic Shea
FIGURE 7-2.
Surgical Approaches to the External Ear Canal and Middle Ear 125
speculum holder; other designs are modifications
incorporating surgeons' various preferences.
With the use of a flat elevator, preferably a duckbill
or large curved canal knife, the skin is gently sepa-
rated from the underlying bone (Fig. 7-2D). Special
care must be observed when a prominent tympano-
mastoid suture is present; simply lifting the skin will
cause tears in the flap. A smaller sharp instrument
(for example, a No. 1 straight knife or sickle knife) is
helpful in releasing connective tissue attachments.
Separation must be slow and careful in order to
preserve the flap intact. The suction tip (finger off
the hole) is used behind (posterior to) the elevator.
The skin is elevated evenly, avoiding tunneling, and
the flap is elevated until it reaches the annulus. At
this point, greater magnification may be used (for
example, 16 x) in the microscope. All bleeding must
be controlled, and entrance to the middle ear should
be "dry. " A No. 20 suction tip is preferred for the
middle ear. Small sources of bleeding can be stopped
using "Adrenalin tape. " Occasionally cautery is
needed; however, it is preferable to avoid any edema
or necrosis, such as that caused by cauterization, in
these thin flaps.
The middle ear is entered beneath the annulus with
a duckbill or curved canal knife (Fig. 7- 2E). If there
is adequate visualization, the site of entrance is not
crucial; in general, however, it is preferable to enter
interiorly toward the round window rather than
toward the ossicles. Once the annulus is separated,
a drumhead elevator is introduced and the annulus
is gently lifted by a sweeping motion from 6 to 12
o'clock through the whole extent of the exposed
annulus. The chorda tympani should be gently and
carefully moved out of the field of vision; if this
would stretch it, the best course is simply to cut it
with a Bellucci scissors (Fig. 7-3A, B). In cases in
which adhesions or thickened mucoperi osteum ob-
scure visualization of the middle ear structure, it is
imperative to enter the middle ear cautiously and
systematically. Avoiding damage, particularly to os-
sicles (or their remnants) or an exposed facial nerve,
is crucial. The cavity is entered inferiorly, where the
round window niche area is found; from there the
surgeon works toward the ossicles. If they are still
obscured, or if the anatomy is (or seems) distorted,
a small atticotomy is done. The head of the malleus
and body of the incus (which usually are present
even if extensive ossicular erosion has occurred) are
identified, and the dissection is started from this
point. ( Beware of the tensor tympani area, where the
facia] nerve might be dehiscent.) The chorda tympani
can also serve as a guide to follow. Whatever the
choice, thickened tissue should not be removed
blindly.
Exposure of the Middle Ear
The middle ear is visualized and the mucosa as
well as the different anatomi c structures are identi-
fied before any planned procedure is begun (Fig. 7-
3C). Methodical evaluation of the cavity is good
practice. This includes evaluation of ossicular mobil-
ity, which is done by mobilizing the long process of
the malleus with a drumhead elevator or joint knife
(Fig. 7- 3D), followed by palpation of the incus and
stapes (Fig. 7- 3 E). Testing the mobility of the stapes
includes the footplate, not the head alone. If more
complete exposure of the oval wi ndow is needed,
the posterior canal wall should be curetted. The tip
of the curet should always be in view. A sharp curet
that is as large as possible should be utilized. An
angled curet is used to remove the bone of the
posterior canal, including the area of the scutum. In
general, it is better to curet from 12 to 6 o'clock in
order to avoid accidental dislocation of ossicles. The
curet should not be used in a perpendicular fashion.
Special time should be dedicated to completely re-
moving bone fragments, which if left in the middle
ear stimulate localized tissue reaction and make the
cavity prone to infection. Again, for good visualiza-
tion it is important to position the patient appropri-
ately, with the surgeon and microscope in the correct
position as well.
Closure
Upon completion of middle ear work ( procedures
are described in specific chapters), the flaps are
repositioned. At the same time, they are carefully
cleansed, fraed of debris with thin suction tips, a
joint knife, or both, and examined for tears. The
tympanic membrane also is examined for small punc-
tures or lacerations; if any are present, their edges
are closely approxi mated, and small pieces of Gel-
foam are used to cover them. The paramount consid-
eration, requiring great care, is anatomic position.
The fact that flaps shrink initially must be taken into
account.
Revisions
Ideally, previous reports should be available. Re-
visions shoi'ld be approached as a "box of surprises"
from beginning to end. The main points to keep in
Surgical Approaches to the External Ear Canal and Middle Ear
FI GURE 7-3.
Surgical Approaches to the External Ear Canal and Middle Ear 127
mind are that flaps are quite thin and tear easily,
and that bony defects of the ear canal are to be
expected. Careful incisions and elevation are used.
Adhesions are common and should be sectioned
carefully and sharply in order to avoid tears. Repo-
sitioning of the flaps should be carefully done and
anatomically adequate; adequate packing is of the
utmost importance as well.
Packing
Alternatives to packing exist, depending upon the
particular case and the surgeon's preference. They
are all satisfactory and will work if done correctly.
Different materials can be utilized; if used properly,
most of them suffice. Excessive pressure must be
avoided. Antibiotic or steroid ointments or solutions,
or both, are useful in preventing localized inflam-
mation and infection. Only the most common pack-
ing techniques will be mentioned.
1. A basket is fashioned from surgical rayon or
Owen's silk strips moistened with antibiotic or ste-
roid ointment. Cotton soaked in antibiotic solution
fills the space, and the silk is used as a rosebud
packing. A 1/2-in gauze pack with antibiotic ointment
is placed in the lateral third of the canal (Fig. 7- 4A-
C). This type of packing provides adequate pressure
to keep the flaps flat, but not enough to damage
them. It should be removed at intervals of one week
for the gauze and two weeks for the rosebud; if left
for a longer period granulation tissue invades the
silk, making it difficult if not impossible to remove it
by simply pulling.
2. The canal is filled with Gelfoam soaked in
antibiotic solution. It is placed initially in layers, with
Gelfoam strips covering all areas of incision. The
lateral aspect of the canal can be filled with ointment,
or a piece of sterile cotton can be placed (Fig. 7-4D).
The disadvantage of this method is that it takes a
long time for the Gelfoam to come out spontaneously;
thus removal must be done very carefully in order
to avoid flap disruption. Gelfoam promotes granu-
lation. This type of packing may require the use of
otic drops or ointments.
3. The canal is filled with an antibiotic ointment
as the sole packing, and a piece of cotton is placed
in the meatus (Fig. 7- 4E). This method of packing
requires perfect approximation of intact flaps.
4. The incisions are completely covered with com-
pressed, dry Gelfoam in strips, and a flat, round
piece of Gelfoam is placed over the tympanic mem-
brane. Ointment is then inserted into the canal
through a syringe with an 18-gauge needle (Fig. 7-
4F). Gelfoam provides some stimulation for granu-
lation, favors healing, and discourages maceration of
the skin flaps.
Canalplasty in Exploratory
Tympanotomy
If the canal is small or "tight" owing to thick skin
or anterior "bony overhang that prevents satisfactory
visualization despite adequate approach and posi-
tioning, a canalplasty becomes a very useful proce-
dure (Fig. 7- 5) .
Highlights
1. Before performing a canalplasty:
A. Ensure that the approach is the best one.
B. Ensure that the positioning of the patient and
surgeon is adequate.
2. Use curets as needed.
3. Protect the anterior wi ndow shade flap.
4. Drill the anterior wall carefully.
5. Carefully remove all debris.
Pitfalls
1. Drilling the skin flaps.
2. Exposing the temporomandibular joint capsule
anteriorly.
3. Inadequately removing bone dust and debris,
which leads to inflammation and infection.
Procedure
An anesthetic and vasoconstrictors are injected
into the anterior wall. The purpose is to expose the
bony canal and safely remove as much bone as
needed for adequate exposure. This can be accom-
plished with an "anterior window shade" with a
horizontal component and two vertical limbs; the
vertical limbs preferably should not involve the vas-
cular strip. The horizontal incision can be made
medially or laterallythat is, immediately above the
annulus or at the bony cartilaginous junction. In the
medial horizontal incision, the skin is gently elevated
laterally as a flap with a duckbill elevator or curved
Surgical Approaches to the External Ear Canal and Middle Ear
FIGURE 7-4.
Surgical Approaches to the External Ear Canal and Middle Ear
F I G UR E 7-5.
130 Surgical Approaches to the External Ear Canal and Middle Ear
canal knife, and gently rolled anteriorly (Fig. 7 - 5 A,
B,). This skin is very thin and tears easily; thus lifting
must be done carefully. In the lateral horizontal
incision, a flap is developed inferiorly until it reaches
the annulus (Fig. 7 - 5 C, D). Before drilling, the sur-
geon must ensure that the flaps are safely flattened
in order to avoid drilling them. It is a good idea to
cover them with a strip of Owen's silk for added
protection; if the flaps are touched by the drill bit,
the silk will be trapped. A drill bit large enough to
be safe but small enough to leave room for drilling
should be used; it can be supplemented with curets
as needed. Proper use of curets should be learned;
they are safe and very effective.
Enough bone should be removed to permit visu-
alization of the anterior annulus. Care must be taken
to avoid entering the temporomandi bular joint an-
teriorly. If the temporomandibular joint is entered
despite these precautions, a small defect may be
created that is extracapsular; if this is the case, no
particular coverage is needed except for the flap. In
obtaining satisfactory visualization of the entire an-
nulus, it should be remembered that adequate posi-
tioning of the patient's head, and of the surgeon,
will avoid unnecessary drilling. Exposure of posterior
mastoid cells is not a major problem; they should be
adequately covered with the skin flap. Once the
entire bone work has been done, time should be
allotted for complete removal of bone fragments in
order to prevent local tissue reaction and possible
infection. The flaps are completely elevated poste-
riorly; the anterior flap ("window shade") is anatom-
ically repositioned and all bleeding vessels are con-
trolled (Fig. 7 - 5 E) . Then, and only then, can the
middle ear be entered.
Endaural Approach
Highlights
1. Same as with the transcanal approach.
2. Control bleeding before entering the middle
ear.
3. Position the two-prong retractors properly and
carefully.
Pitfalls
1. Same as with the transcanal approach.
2. Exposing or damagi ng the helix with a Lempert
11 incision.
3. Inadequately packing and positioning the flap i,
resulting in adhesions or stenosis.
The endaural approach can be used for an explor-
atory tympanotomy, a tympanoplasty, and a masto-
idectomy, and is particularly useful and safe (or
revision surgery. It is useful, as well, for "tigr^"
canals and canals with thick skin. This approaca
utilizes different sizes of incisions according to neec,
varying from a minimal to a large Lempert II incision
(described below). It is insufficient for large mastoid
cavities and does not provide a good view of the
anterior annulus unless a canalplasty is done.
Position, inspection, and cleansing are done as i i
transcanal procedures. Injection of local anesthefcc
with vasoconstrictors is similar as well, except thct
additional injections are made between the tragus
and helix (at the incisura) and immediately anteri cr
to the helix (Fig. 7 - 6 A) . The endaural approac l
avoids the use of an ear speculum and provides a
direct view of the middle ear.
Incisions
For purposes of exposure, it is best to use a curved
nasal speculum. Incisions are made with a scalp-'l.
The first incision ( Lempert I) is made semicircumfer-
entially between 6 and 12 o'clock on the poster or
wall at the bony cartilaginous junction (Fig. 7 - 6 >')
This incision must extend down to the bone. T >.e
second incision ( Lempert 11) runs between the trag JS
and helix and incisura; care must be taken not 'O
expose or cut the helix. The extension of this incisi >n
depends upon the degree of exposure needed, vary-
ing from a few millimeters (for an exploratory tym-
panotomy) to a full 3. 4 cm (for a mastoidectom
1
).
This incision is made in the ear. Caution must ie
exercised not to deepen it immediately after going
through the subcutaneous tissue, since branches' :>f
the superficial temporal artery and vein are prese it
in this area; too deep a cut also may section t ' i e
temporal fascia, which might be needed for grafting
purposes. It is important to completely section the
connective tissue and to expose the bony canal at t! ie
level of the incisura, allowing more space. Snv 11
bleeding vessels are cauterized. The remaining pos-
terior canal skin (cartilaginous portion) is preserved
and gently elevated with a small periosteal el evat e,
leaving the whole posterior bony canal clearly e ;-
posed (Fig. 7 - 6 C) . On occasion, a small free sk'n
graft can be taken safely from this area. Two tw..-
prong retractors are used for exposure. It is useful o
position them at right angles to each other, one
Surgical Approaches to the External Ear Canal and Middle Ear 131
FIGURE 7 - 6 .
130 Surgical Approaches to the External Ear Canal and Middle Ear
canal knife, and gently rolled anteriorly (Fig. 7 - 5 / 4 ,
B,). This skin is very thin and tears easily; thus lifting
must be done carefully. In the lateral horizontal
incision, a flap is developed inferiorly until it reaches
the annulus (Fig. 7 - 5 C, D). Before drilling, the sur-
geon must ensure that the flaps are safely flattened
in order to avoid drilling them. It is a good idea to
cover them with a strip of Owen's silk for added
protection; if the flaps are touched by the drill bit,
the silk will be trapped. A drill bit large enough to
be safe but small enough to leave room for drilling
should be used; it can be supplemented with curets
as needed. Proper use of curets should be learned;
they are safe and very effective.
Enough bone should be removed to permit visu-
alization of the anterior annulus. Care must be taken
to avoid entering the temporomandi bular joint an-
teriorly. If the temporomandibular joint is entered
despite these precautions, a small defect may be
created that is extracapsular; if this is the case, no
particular coverage is needed except for the flap. In
obtaining satisfactory visualization of the entire an-
nulus, it should be remembered that adequate posi-
tioning of the patient's head, and of the surgeon,
will avoid unnecessary drilling. Exposure of posterior
mastoid cells is not a major problem; they should be
adequately covered with the skin flap. Once the
entire bone work has been done, time should be
allotted for complete removal of bone fragments in
order to prevent local tissue reaction and possible
infection. The flaps are completely elevated poste-
riorly; the anterior flap ("window shade") is anatom-
ically repositioned and all bleeding vessels are con-
trolled (Fig. 7 - 5 E) . Then, and only then, can the
middle ear be entered.
Endaural Approach
Highlights
1. Same as with the transcanal approach.
2. Control bleeding before entering the middle
ear.
3. Position the two-prong retractors properly and
carefully.
Pitfalls
1. Same as with the transcanal approach.
2. Exposing or damaging the helix with a Lempert
II incision.
3. Inadequately packing and positioning the flap i,
resulting in adhesions or stenosis.
The endaural approach can be used for an explor-
atory tympanotomy, a tympanoplasty, and a masto-
idectomy, and is particularly useful and safe tor
revision surgery. It is useful, as well, for "tigHj?"
canals and canals with thick skin. This approaca
utilizes different sizes of incisions according to neec,
varying from a minimal to a large Lempert II incision
(described below). It is insufficient for large mastoid
cavities and does not provide a good view of the
anterior annulus unless a canalplasty is done.
Position, inspection, and cleansing are done as :i
transcanal procedures. Injection of local anesthetic
with vasoconstrictors is similar as well, except thct
additional injections are made between the tragus
and helix (at the incisura) and immediately anteri cr
to the helix (Fig. . 7 - 6 / 4 ) . The endaural approac 1
avoids the use of an ear speculum and provides a
direct view of the middle ear.
Incisions
For purposes of exposure, it is best to use a curved
nasal speculum. Incisions are made with a scalp.'l.
The first incision ( Lempert 1) is made semicircumfor-
entially between 6 and 12 o'clock on the poster or
wall at the bony cartilaginous junction (Fig. 7 - 6 i).
This incision must extend down to the bone. T le
second incision ( Lempert 11) runs between the trag js
and helix and incisura; care must be taken not ro
expose or cut the helix. The extension of this incisi >n
depends upon the degree of exposure needed, vary-
ing from a few millimeters (for an exploratory tym-
panotomy) to a full 3/ 4 cm (for a mastoidectonv ).
This incision is made in the ear. Caution must te
exercised not to deepen it immediately after going
through the subcutaneous tissue, since branches'of
the superficial temporal artery and vein are presc it
in this area; too deep a cut also may section t'ie
temporal fascia, which might be needed for grafting
purposes. It is important to completely section the
connective tissue and to expose the bony canal at tlie
level of the incisura, allowing more space. Srmll
bleeding vessels are cauterized. The remaining pos-
terior canal skin (cartilaginous portion) is preserved
and gently elevated with a small periosteal el evat e,
leaving the whole posterior bony canal clearly e:-
posed (Fig. 7 - 6 C) . On occasion, a small free skm
graft can be taken safely from this area. Two twu-
prong retractors are used for exposure. It is useful o
position them at right angles to each other, one
Surgical Approaches to the External Ear Canal and Middle Ear
FIGURE7 - 6 .
132 Surgical Approaches to the External Ear Canal and Middle Ear
pointing cephalad (superiorly) and the other caudad
(posteriorly); this provides better exposure and sta-
bility and is less inconvenient for the surgeon. Tem-
poral fascia is harvested at this point (discussed in
Chapter 12) and all bleeding vessels are controlled.
With the scalpel, incisions can be made at 6 and 1 or
2 o'clock (Fig. 7- 6 D). These incisions allow for easier
development of the flap; however, the flap can be
elevated without the incisions. The flap is elevated
in the same manner as in a transcanal incision. The
same principles and technique also apply for a can-
alplasty.
Closure
The flap is repositioned anatomically; particular
attention is paid to repositioning the skin, which
must cover the cartilaginous canal. Subcutaneous
tissues are approximated with interrupted absorbable
sutures (for example, 3- 0 chromi c catgut). Approxi-
mation does not need to be very tight at the incisura.
Skin is approximated with absorbable 4- 0 silk or
nylon sutures. The first skin suture should be at the
incisura; as in other ear incisions, there is remarkably
good healing in this area. Packing is done as in
transcanal procedures for the bony canal; however,
it is best to use 1/2-in gauze impregnated with anti-
biotic or steroid ointment in the lateral third (carti-
laginous canal), followed by a mastoid dressing. The
gauze and the skin sutures are removed one week
after the procedure. At this time the authors usually
fill the space with antibiotic ointment for one addi-
tional week.
Postauricular Approach
Highlights
1. Same as for transcanal and endaural ap-
proaches.
2. The postauricular incision should be made plane
by plane.
3. The canal should be reached in the "avascular"
plane.
4. Cleansing of all debris should be done carefully.
Pitfalls
1. Tearing of the canal with the three-prong re-
tractors.
2. Inadequately cleansing debris, learing to
wound infection.
The postauricular approach can be used for an
exploratory tympanotomy, a tympanoplasty, and a
mastoidectomy. It provides a good view of he an-
terior rim of the annulus, unless there is a prr^ ninent
bony overhang or a "tight" canal; ho we v^ iti is
useful for dealing with these two problems as we I.
Position, inspection, and cleansing are done in
transcanal and endaural procedures; however, pa-
tient preparation and shaving of hair is different (see
Chapter 6 ). Injection of a local anesthetic is similar
to the transcanal procedure, as far as the anal is
concerned; however, a postauricular injection s nec-
essary in the whole area where the incision i< to be
made, as well as in the posterior aspect of the canal
from behind. It is useful to lift the auricle, 7ull it
forward, and inject posteriorly, while feeling the tip
of the needle and the flow of anesthetic and vaso-
constrictors with the index finger placed in th* mea-
tus of the canal; this maneuver ensures arVquate
injection.
Incisions
The classic incision is made 3/4 cm behind the
posterior sulcus, with the inferior end dev ating
posteriorly. In children, the incision is higr and
posterior with the inferior limb far posterioi since
the facial nerve can be very superficial in its exit at
the stylomastoid foramen (because of lack of devel-
opment of the mastoid tip). For cosmetic pu poses
the incision can be made in the crease itself, I ut the
cosmetic advantage is relative; this location lends
itself to minor healing problems, small epic ermal
cysts, and so on. An additional incision that an be
made is the posterosuperior ( Portmann), whu h is a
compromi se between the posterior incision at d the
anterosuperior ( Hermann) incision. (In spite of its
good exposure, the latter is not used because -i may
lead to necrosis of the helix.) The posterosu ?erior
incision provides excellent exposure.
Procedure
The Incision is made with a scalpel and deepened
perpendicularly through subcutaneous tissues with-
out advancing too far. The purpose is to read i the
musculo-aponeurotic or "avascular" plane. Cai t er"
can be used for bleeding vessels. If the planet ar<'
Surgical Approaches to the External Ear Canal and Middle Ear 133
developed carefully, large branches of the posterior
auricular artery usually will not be sectioned; if this
does occur, it is best to tie them with a nonabsorbable
suture. Many surgeons use cutting cautery in the
skin, which is effective in terms of surgical time and
dryness of the field. However, this must be weighed
against the disadvantage of skin healing secondary
to a cutting cautery burn.
If the right plane is reached, the auricle is pulled
anteriorly (forward) and the cartilaginous canal is
identified, as well as the spine of Henle. (At this
point the temporal fascia can be harvested; this is
discussed in Chapter 12.) Once this is done, the
connective tissue plane behind the cartilaginous canal
can be developed sharply and safely. All bleeding
vessels, if there are any, should be controlled. Ele-
vating the plane toward the zygomatic root gains
room to mobilize the auricle forward (anteriorly)
easily (Fig. 7- 7A). A circumferential incision is made
at the bony cartilaginous junction posteriorly, as in
' the endaural procedure. ( We are discussing explor-
atory approaches alone; other types of flaps for other
purposesfor example, Korner'swill be dealt with
later.) A piece of twill tape passed gently through
the incision ensures that the skin of the meatus
posteriorly is not torn when using a retractor, and at
the same time serves to keep this flap out of the field
of vision (Fig. 7- 7B) . With the use of a three-prong
Wullstein retractor, the auricle (pinna) is gently
pulled anteriorly with the posterior cartilaginous
canal, protected by the twill tape (Fig. 7- 7C). Care
must be taken not to tear this skin and cartilage. If a
Wullstein retractor is not large enough, a modified
Schuknecht three-prong retractor is used. (This is
usually necessary in a mastoidectomy but uncommon
in exploratory procedures. )
From this point on, the same procedure is followed
as in endaural or transcanal incisions. Closure is
preceded by careful removal of debris. The packing
of the bony canal is similar to that in other ap-
proaches; the lateral aspect of the canal (cartilagi-
nous) is packed as in the endaural approach. Post-
auricular closure is done with interrupted absorbable
sutures for subcutaneous tissues (for example, 3-0
chromic catgut). This layer should be approximated
carefully; otherwise, the pinna may lack adequate
subcutaneous support and show a tendency to proj-
ect anteriorly. Skin is approximated with interrupted,
nonabsorbable silk or nylon. Some surgeons close
the skin with 4-0 catgut sutures; although this
method may be adequate, the authors do not use it.
A mastoid dressing is applied. Removal of sutures
and packing is done as in the endaural approach.
Simple Mastoidectomy as
a Surgical Approach
A simple mastoidectomy is described here as a
general surgical approach for different procedures; it
is discussed as a specific procedure in Chapter 5.
Mastoid procedures for chronic otitis are described
separately in Chapter 10 .
Aim
Exenteration ( removal) of all mastoid air cells while
maintaining the integrity of the posterior canal.
Highlights
1. Skin incision is performed with the scalpel
perpendicular to the skin.
2. Incision should be deepened in layers.
3. Careful elevation of intact periosteum should
be done.
4. Retractors must be adequately positioned.
5. Complete exposure of landmarks is important.
6 . Carefully close in layers.
Pitfalls
1. Tearing of the skin of the posterior ear canal.
2. Inadequate exposure.
3. Injuring a high sigmoid sinus.
4. Injuring the facial nerve by going:
A. Deep to the horizontal semicircular canal.
B. Too far anterior in the digastric ridge.
5. Dislocating the incus by drilling blindly into
the antrum area.
6 . Exposing the dura mater.
7. Drilling the semicircular canals.
Positioning, patient preparation and draping, and
injection have already been discussed. As described
in previous chapters, a classic postauricular incision
will be used, starting at the level of the linea tem-
poralis and following the contour of the external
meatus to turn posteroinferiorly at the level of the
mastoid tip.
FIGURE 7-7.
Surgical Approaches to the External Ear Canal and Middle Ear 135
Incision and Exposure
Before initiating postauricular work, it is a good
idea to place a piece of sterile cotton in the canal in
order to avoid accumulation of debris and bone dust.
The incision is made in layers with a scalpel held
perpendicularly to the skin. Subcutaneous vessels
are cauterized. A plane between the musculo-apo-
neurotic layer and connective tissue is reached by
sharp dissection, and developed. It is possible in this
plane to avoid damagi ng branches of the posterior
auricular artery; if damage does occur, it is better to
ligate than to cauterize them.
The periosteum is identified and sectioned, follow-
ing the contour of the external ear canal. Vertical
incisions at 45-degree angles are made at 6 and 12
o'clock (toward the linea temporalis and toward the
mastoid tip) (Fig. 7-SA). The intact periosteum is
elevated carefully, using periosteal elevators. This is
important for closure, since re-establishing the peri-
osteum in position will avoid a marked postauricular
depression. As soon as the periosteum is elevated,
the landmarks become apparent. It is useful to expose
the root of the zygoma; this provides better mobility
when positioning the retractors. Two three-prong
retractors are positioned at right angles to one an-
other (Fig. 7- 8C).
Specific surgical steps are described in Chapter 5
( pages 45- 47). The discussion here will focus on
closure and treatment of intraoperative complica-
tions.
Closure
Careful washing and thorough removal of all de-
bris and bone dust are of the utmost importance in
order to prevent postoperative inflammation and
infection. The retractors are removed, and the peri-
osteal flap is repositioned and secured to the poste-
rior canal by nonabsorbable sutures, (f the flap is
intact and the approximation is adequate, marked
postauricular depression will be avoided. Subcuta-
neous tissues are approximated with layers of inter-
rupted absorbable sutures (for example, 3-0 or 2-0
chromi c catgut), and skin with interrupted nonab-
sorbable sutures (for example, 4-0 silk or nylon),
making sure that the skin and subcutaneous sutures
do not overlap. A mastoid dressing is then applied.
Intraoperative Complications
or Problems
1. Facial nerve trauma.
2. Exposure of the dura mater.
3. Drilling of the semicircular canals.
4. Damage to the sigmoid sinus.
5. Dislocation of the incus.
Facial Nerve Trauma. Inadvertent exposure of the
facial nerve sheath does not necessarily imply injury
to the nerve and requires no treatment. However, if
the nerve itself is injured in its course through the
fallopian canal, it should be opened for several mil-
limeters to ensure continuity. The nerve sheath should
not be opened unless discontinuity of nerve fibers is
suspected. Opening of the sheath might allow in-
growth of fibrous tissue, which can compromi se
nerve regeneration, if discontinuity of fibers exists,
they should be apposed cleanly to each other. If the
injury is severe and includes maceration, the nerve
should be sharply and cleanly incised and an end-
to-end anastomosis performed (see Chapter 18). If
the traumatized segment is too broad, nerve grafting
should be done. Exposed nerve fibers should be
covered in order to avoid ingrowth of fibrous tissue.
They should not be covered with fascia, since fascia
provides such ingrowth; materials that discourage
fibrous tissbe ingrowth (for example, thin sheets of
gold foil) should be used.
Facial paralysis that is evident immediately post-
operatively may be caused by intraoperative injury,
the effect of local anesthesia, or pressure from pack-
ing on a dehiscent nerve. Paralysis from such sources
necessitates immediate re-exploration unless the sur-
geon is certain there is no facial nerve damage, in
which case packing and pressure should be released.
Steroids can be argued against, but in this case the
authors believe their use may be beneficial. Delayed
facial paralysis (developing after the patient has re-
covered without paralysis) requires loosening of the
packing and should be treated as Bell's palsy.
Exposure of the Dura Mater. Exposure of the dura
mater during mastoidectomy can happen at the teg-
men (middle cranial fossa dura) and at the posterior
cranial fossa dura. Without penetration or rupture of
the dura itself, it is of no significance except as a
reflection of poor technique. If the dura is torn a
cerebrospinal fluid leak will result, with subsequent
potential for infection. Small leaks in the middle
cranial fossa often cease spontaneously because of
the abundant arachnoid that is present. A small piece
FIGURE 7-8.
Surgical Approaches to the External Ear Canal and Middle Ear 137
of fascia can be used for coverage, after it is ascer-
tained that the surrounding dura is intact. ( Remove
a few millimeters in each direction.) The fascia can
be tucked in place. Larger defects can be closed by
using cartilage or bone lateral to the fascia, or both.
Intraoperative and postoperative antibiotics are used
as in all other complications involving areas or struc-
tures beyond the confines of the mastoid or middle
ear cavity. Antibiotics that cross the blood-brain
barrier should be used; this is an important but
frequently overlooked point.
Posterior cranial fossa dura has less arachnoid,
and leaks there are occasionally quite profuse. As
soon as the leak occurs, a large piece of Gelfoam or
twill tape is placed over the defect and finger pres-
sure is applied. This is followed by tissue grafting
with temporal muscle medially and fascia laterally.
The cavity is then covered with large pieces of
Gelfoam, and, if necessary, filled under pressure. If
the flow continues, an indwelling lumbar catheter
rhay. be placed in order to diminish the cerebrospinal
fluid pressure for several days.
Drilling of the Semicircular Canals. Damage occurs
most commonly at the dome of the lateral (horizontal)
semicircular canal and occasionally at the posterior
semicircular canal when exposing Trautmann's tri-
angle. If the damage is recognized before injury to
the membranous labyrinth occurs, sealing the fistula
with Gelfoam or tissue graft may prevent serious
sequelae. Damage to the membranous labyrinth re-
sults in an irreversible disturbance in hearing and
balance, except on rare occasions in which previous
involvement of the labyrinth has allowed its com-
partmentalization.
Damage to the Sigmoul Sinus. The best way to deal
with this problem, as with all other complications, is
to avoid it. This can be achieved bv having a good
set of preoperative mastoid films that provide infor-
mation on the location of the sigmoid sinus (for
example, "high-lateral," "low-medial," "anterior,"
etc. ), and by developing the mastoidectomy step by
step. Ear surgery is not for "racing surgeons."
Laceration of the sigmoid sinus results in profuse
hemorrhage. A similar problem can occur with a
dehiscent jugular bulb in the hypotympanum. Bleed-
ing can often be stopped by immediate, firm, appli-
cation of large pieces of Gelfoam and twill tape and
by finger pressure, followed by application of oxi-
dized cellulose (oxycel). This in turn is covered by
pieces of Gelfoam and fascia if needed. At the end
of the procedure, extradural hematoma should be
ruled out.
Dislocation of the Incus. This complication entails
exploratory tympanotomy and repositioning of the
incus in its normal anatomic position (see Chapter
11).
Posterior Tympanotomy (Facial
Recess) as a Surgical Approach
The posterior tympanotomy (facial recess) proce-
dure is included here as a general surgical approach
for different purposes; aim, highlights, pitfalls, and
procedure are described in Chapter 5. Specific indi-
cations are discussed in pertinent preceding chapters.
Closure is exactly the same as in a simple masto-
idectomy. Management of complications also is iden-
tical except for those inherent in this specific ap-
proach.
Intraoperative Complications
or Problems Inherent
in This Approach
1. Damage to the tympanic membrane.
2. Perforation of the bony external ear canal.
Damage to the tympani c membrane implies a
transcanal exploration. The borders of a small tear
are cleansed and approximated anatomically and
covered with Gelfoam. A larger defect necessitates a
graft (to be discussed in Chapter 12).
Small perforations of the posterior wall of the
bony external ear canal are not significant and need
no repair except for adequate coverage with skin
flap. Major defects may require posterior wall recon-
struction.
Mastoidotomy as a
Surgical Approach
Aim
Visualizing the antrum and establishing (or re-
establishing) communication between the mastoid
and middle ear cavities.
The highlights, pitfalls, technique, and complica-
tions of a mastoidotomy are essentially those of a
cortical mastoidectomy (see Chapter 5), but the
amount of bone removed is much less. This proce-
138 Surgical Approaches to the External Ear Canal and Middle Ear
dure is performed using a postauricular or endaural
approach. Drilling is done in the fossa mastoidea
toward the antrum. Whether the purpose is to re-
move tissue blockage, improve aeration to the middle
ear, or introduce an electrode into the middle ear,
the opening should be large enough to allow visu-
alization of the antrum.
Meatoplasty
Meatoplasty is discussed in this chapter as a gen-
eral concept owing to its practical and often crucial
importance in otologic procedures. The meatus con-
sists of skin, subcutaneous tissue, cartilage, and
underlying bone. It is essential to consider all of
these structures in a meatoplasty; adequate treatment
of the soft tissues combined with insufficient atten-
tion to the underlying cartilage or bony meatus, or
both, might result in an inadequate meatoplasty.
Meatoplasty is essential for obtaining a good surgical
result in tympanomastoid surgery and in tympano-
plasty ( when indicated and usually associated with
canalplasty).
Large canals do not need a meatoplasty. The
procedure is used for small canal entrances (open-
ings), whether congenital or acquired (by disease or
by surgery). A normal-sized meatus allows for proper
aeration and self-cleansing of the canal, and adequate
sound conduction. The procedures described here
(exemplified for practical purposes in open- and
closed-cavity tympano-mastoi dectomy) apply in
principle to other surgical cases as well.
With the understanding that a postauricular and
an endaural approach can be used interchangeably,
a postauricular approach is described in the meato-
plasty for an open-cavity tympano-mastoi dectomy,
and an endaural approach for a closed-cavity tym-
pano-mastoidectomy. The development of a Korner's
flap will be described in the former, as well.
Aim
To provide a well-epithelialized meatus that is
wide enough to aerate the ear canal and allow proper
sound conduction and self-cleansing.
Highlights
1. Maintain continuity and integrity of the skin
flap.
2. Effect meticulous hemostasis.
3. Thin the skin flap.
4. Excise conchal cartilage (the cornerstone of
meatoplasty).
5. Drill underlying bone (if necessary).
6. Use sutures to keep the meatus open. >
7. Cover all open areas.
1
8. Postoperative care must be adequate and s e-
quent.
Pitfalls and Complications
t. Leaving skin flap with a thin base.
2. Tearing of skin flap.
3. Excessive bleeding.
4. Leaving open areas with granulation ti ssi e
formation.
5. Displacing a flap.
6. Perichondritis.
7. Meatal stenosis.
Meatopl asty in Open-cavity
Tympano- mas t oi dect omy
Since a meatoplasty can cause some bleeding, i
can be deferred until the middle ear and mastoic
work is completed, grafts are placed, and the dista
third of the canal is packed. Meticulous hemostasi:
should be exercised. In an open-cavity mastoide':
tomv, a Korner's flap is quite useful in providing
skin coverage for the newlv created mastoid cavity.
The flap is developed by making vertical incisions in
the skin of the external auditorv canal at 6 and l'
1
.
o'clock with a straight canal knife. They are con-
nected by a horizontal incision made with a curved
canal knife at 5 mm from the tympanic annulus (Fig".
7 - 9 A ) . 1 he vertical incisions are then extended to the
conchal bowl (Fig. 7 - 9 8 ) . It is important to keep the
base of the flap wide at the conchal bowl level. Th(
subcutaneous tissue of the flap is generally quite
thick. It can be thinned carefully with a sharp scissors
or scalpel, avoiding damage to the overlying skir
(Fig. 7 - 9 C) .
An opening is considered adequate when (hi
surgeon's index finger can be introduced easily into
the meatus. For practical purposes, a meatus canno<
be made "too wide"; there is always a tendency
toward reduction in size ( narrowing). In order to
keep the meatus open and provide better apposition
of tissues for healing, two permanent sutures can be
placed, bringing together the subcutaneous layer
with the posterior margin of the postauricular inci-
sion (Fig. 7 - 9 D ) . It is important to prevent postop-
Surgical Approaches to the External Ear Canal and Middle
FIGURE7 - 9 .
140 Surgical Approaches to the External Ear Canal and Middle Ear
erative stenosis by controlling formation of granula-
tion tissue. Clean edges of the flap and good skin
coverage of the mastoid bowl are of paramount
importance. A Thiersch graft can be performed dur-
ing the primary procedure for these purposes, or
after three weeks if open areas with granulation
tissue are present; this should be necessary only
occasionally. (See the discussion of the Thiersch graft
in this chapter.) A steroid-saturated, firm pack is
applied and left in place for two weeks; upon its
removal, all granulations (if any) are curetted and/or
cauterized, and a steroid-antibiotic ointment is ap-
plied. Frequent and meticulous postoperative care is
bask to successful healing in meatoplasty and in
mastoid cavities in general.
An additional point: If a Korner's flap is not used
in a postauricular approach, a horizontal incision can
be made i n the bony cartilaginous junction with two
vertical incisions at 6 and 12 o'clock, creating a
rectangular flap (Fig. 7 - 9 E) . With this flap, the basic
principles described above apply equally. Other
types of flaps can be used according to need, such
as a vertical incision, an inverted T, or an inverted Y
(Fig. 7 - 9 F ) . Regardless of the flap used, the important
point is to provide adequate skin coverage for the
newly created surface area, ft is crucial to remember
that the meatus also comprises cartilage and bone;
that the flap is an important part, but only a part, of
the meatoplasty. Despite a flap that is beautifullv
designed "on paper," an inadequate meatoplasty
may result because of lack of attention to the under-
lying subcutaneous tissues, cartilage, or bonv mea-
tus.
Meatopl asty in Cl osed-cavity
Tympano- mast oi dect omv
An endaural Lempert I incision is made at a level
approximately 7 mm below the mastoid cortex level.
A Lempert II incision is made that is large enough
to admit the surgeon's forefinger freely. The bonv
canal, especially the posterior bony canal, is enlarged;
conchal cartilage is then removed by carefully evert-
ing the conchal skin and using a sharp scissors or
scalpel (Fig. 7 - 1 0 ) . Packing, suturing, and postoper-
ative care are identical to those for an open-cavity
mastoidectomy.
Management of Pitfalls and
Complications
A torn skin flap or a flap with poor vascularity
due to a thin base may not survive; however, a thin
flap may, behaving for all practical purposes as i
skin graft. Lack of flap survival necessitates surgicrl
debridement and a Thiersch graft. Excessive bleedin ;
may lead to infection or appearance of granulation
tissue, or both; if bleeding occurs underneath th'-'
flap, the flap may become medially displaced. An
"organized clot" often leads to fibrosis, calling fo
careful elevation of the flap, meticulous hemostasi a. .
debridement, and tight packing. Fibrosis also can
occur when using a tight packing, but there will be
no secondary problems, provided that the packing is
removed at the proper time (no longer than twe
weeks afterward). Management of open areas witl
granulation tissue has already been described. On
occasion, especially when an infected mastoid h. 'j
been dealt with, a perichondritis might occur, cha'-
acterized by edema, induration, and pain over tr ^
entire pinna. In early stages, the possibility of allergy
to the antibiotic ointment or solution must be consic -
ered. These signs ( misnamed "cellulitis") requir
change of antibiotic solution, systemic antibiotic?,
daily (at least twice) soaks with Burow's solution c-
any astringent solution, and application of packing
saturated with antibiotic steroid solution. If t ly
symptoms progress (which they rarelv do), debride
ment, drainage, and placement of drains may be
needed. Cultures should be obtained, if possible.
If general principles, including adequate follow .'
up, are not observed, meatal stenosis requiring i
revision may occur. The meatal skin is carefulh
elevated, the underlying bone (which usually dis
plays new bone formation, bony spicules, ridges
and so on) widelv drilled or curetted, and a largf
meatus developed. Remember that for practical pur
poses a meatus cannot be made too large, only too
small.
Thiersch Graft
Granulation tissue may develop in the mastoid
cavity after canal-wall-down mastoidectomy. Drain-
age may persist from granulation tissue until the
entire mastoid cavity is epithelialized. A Thiersch
graft is a thin skin graft that helps to epithelialize
and eliminate drainage from the mastoid cavity.
Aim
Placing a thin skin graft in the mastoid cavity in
order to achieve complete epithelialization.
Surgical Approaches to the External Ear Canal and Middle Ear 141
Cartilage
RGURE 7-10 .
Highlights Operative Procedure
1. Remove infected granulation tissue.
2. Harvest thin skin from the upper medial arm.
3. Cut the skin into proper sizes on Owen's silk.
4. Cover the entire non-epithelialized mastoid cav-
ity surface with the skin graft.
The procedure usually is carried out under local
anesthesia. Local injection of 1% lidocaine with
1 : 1 00, 000 epinephrine, combined with topical appli-
cation of 4% cocaine solution soaked in 1/2-in gauze
strip, provides adequate anesthesia.
Pitfalls
1. Inadequately removing infected granulation tis-
t e .
2. Harvesting too-thick skin.
Debr i dement of Granul ation Tissue
from Mast oi d Cavity
The mastoid cavity is irrigated with warm saline
to remove any debris or mucopus. Using cupped
forceps, ring ct ret s, and suction tips, all infected
granulation tissue and necrotic tissue is removed;
Surgical Approaches to the External Ea
FIGURE 7-11
Surgical Approaches to the External Ear Canal and Middle Ear 143
any thin, clean, raw tissue over the bone is left intact
(Fig. 7- 11/ 4) . Hemostasis is obtained with 1:10 0 0
topical epinephrine (Adrenalin) soaked in 1/2-in
gauze strip.
Harvesting Thi n Skin
After the mastoid cavity is cleaned out and while
hemostasis is being attained, thin skin is harvested
from the medial upper arm. Local anesthesia is
obtained with 1% lidocaine with 1:10 0 ,0 0 0 epineph-
rine injection. The authors use a razor blade held in
a clamp to harvest very thin strips of skin (Fig. 7-
11B). In order to obtain a thin skin graft, the razor
blade is pressed down only by the weight of the
instrument and a slicing motion is used. The area of
the upper arm where the skin is harvested is made
tight by pulling the lateral part of the arm with the
surgeon's free hand. A thin coat of mineral oil over
the skin helps to harvest thin pieces of skin. The
area of the mastoid cavity requiring a skin graft
determines the amount of skin to be harvested; the
donor site is then dressed with scarlet red or Xero-
form gauze dressing. The thin pieces of harvested
skin are laid on a piece of Owen's silk impregnated
with gentamicin sulfate ( Garamycin) ointment, and
placed on an upside-down Petri dish (Fig. 7- 11C).
Extreme care should be taken to lay the skin on the
Owen's silk with the shiny dermis side up. The skin
and Owen's silk are then cut into the proper size
(usually about 0 . 5 cm) with a sharp scissors.
Skin Graft of Mast oi d Cavity
The gauze strips soaked in topical epinephrine
solution a^e removed from the mastoid cavity. The
pieces of skin and Owen's silk are placed over the
raw tissue|in the mastoid cavity with the dermis side
down ( toward the bone) and the Owen's silk up (Fig.
7- 11D). The entire nonepithelialized surface of the
mastoid cavity is covered carefully; slight overlap of
coverage is acceptable. An eye patch dressing is then
applied over the ear.
Postoper ative Car e
The pieces of Owen's silk are removed in two
weeks. If the skin has taken well, drainage is ended
and only routine care of the mastoid cavity is re-
quired.
FIGURE 7-12.
144 Surgical Approaches to the External Ear Canal and Middle Ear
FIGURE 7- 12
This section at the level of the footplate shows a
dehiscent and bulging facial nerve over the stapes
crura (the most common area of dehiscence). This
photomi crograph serves as a reminder of the impor-
tance of thorough visualization before any drastic
procedures are performed. The facial nerve can be
dehiscent in other areas as well, such as adjacent to
the tensor tympani, in the facial recess, and in the
medial wall of the anterior epitympanic r< cess. A
dehiscent nerve can result in facial paresis or paral-
ysis in cases of acute otitis media, and represents a
potential complication in otologic surgical proce-
dures.
FIGURE 7- 13
This section shows a focus of otosclerosis, but in working vigorously and blindly in the eusiachian
more importantly a dehiscent carotid artery (parallel tube area since complications could be disastrous.
arrows). Although this is uncommon, there is a risk
Surgical Approaches to the External Ear Canal and Middle Ear 145
FIGURE 7- 14
This section shows the presence of a persistent
stapedial artery immediately medial to the footplate
in a middle ear with thickened mucosa and a dehis-
cent facial nerve. This persistence (representing per-
sistence of the embryonal hyoid artery) ts rare and
should not be confused with a normal small arterial
branch that crosses the footplate. Adequate v.suali-
zation and careful dissection are crucial when ex-
ploring an ear with chronic disease.
Pertinent Histopathology
SECTION IV
Specific Surgical
Approaches
CHAPTER 8
External Ear Canal
Procedures
Canalplasty
A canalplasty is a procedure that normalizes the
external auditory canal by removing abnormal bony
growth such as exostosis, removing and replacing
intractably infected skin of the canal, or enlarging
and straightening a severely stenotic and tortuous
canal. Meatoplasty may be done at the same time.
Aim
To restore the normal width and contour of the
external auditory canal and, sometimes, to replace
diseased with healthy skin.
Surgical Steps
1. Endaural or postauricular incision.
2. Elevation of canal skin flap.
3. Widening of the bony canal.
4. Placing back the canal skin flaps or skin graft.
5. Packing and closure.
Pitfalls
1. Exposing the temporomandibular joint capsule
anteriorly.
2. Opening into the mastoid air cells.
3. Damaging the tympanic membrane, ossicles, or
skin flaps.
Operative Procedure
The procedure usually is carried out under general
anesthesia but can also be done under local anes-
thesia. In either case, local injection of 1% lidocaine
with 1:10 0 ,0 0 0 epinephrine is made into the four
quadrants of the external auditory canal. Either an
endaural or postauricular approach can be used.
Exostosis
Large exostoses can cause retention of cerumen,
recurrent inflammation of the canal skin, and even
conductive hearing loss. An endaural approach usu-
ally is adequate. A posterior skin flap is developed
from the bony cartilaginous junction to the annulus
of the tympanic membrane (Fig. 8-1A). The skin over
the exostosis is elevated and preserved. When the
exostoses are too large to permit a canal incision, a
separate incision is made on the top of the exostoses
paralleling the annulus of the tympanic membrane.
Two skin flaps are developed over each exostosis,
one laterally and the other medially based.
When the posterior bony canal with exostosis is
exposed, the exostosis is drilled out with a cutting
bur and diamond bur under continuous irrigation
(Fig. 8- 1B). As the base of the exostosis is removed,
the entire tympanic membrane can be visualized and
150 External Ear Canal Procedui
FIGURE 8-1
External Ear Canal Procedures 151
the canal skin flap becomes better defined. The
annulus of the tympanic membrane is left intact, and
the middle ear is not entered. The remaining bony
canal wall is smoothed down until the canal has a
normal, even contour.
Any other exostoses in the canal are removed in
a similar manner. This is usually easier because the
canal is less crowded and the tympanic membrane is
readily visible. For an exostosis in the anterior canal,
a laterally based anterior "window-shade" flap can
be developed starting from an area just lateral to the
anterior half of the tympanic ring. When drilling the
anterior wall of the canal, care must be exercised not
to enter the temporomandibular joint.
After all the exostoses are removed and the rest
of the canal wall is smoothed down, the skin flaps
are laid back (Fig. 8- 1C). The external auditory canal
is packed with Gelfoam saturated in antibiotic solu-
tion and "wrung out"; Owen's silk strips and pieces
of cotton packing (rosebud packing) also can be used.
The lateral part of the canal and the meatus are
packed with 1/2-in gauze strips saturated with anti-
biotic ointment.
The incision is closed in layers and a mastoidec-
tomy type of pressure dressing is applied.
Intractabl e External Otitis
This procedure is indicated when chronic external
otitis is persistent despite aggressive medical treat-
ment. Usually the canal is obliterated with swollen,
thick canal skin. The operation is usually performed
under general anesthesia. Local injection of 17c li-
docaine with epinephrine helps hemostasis.
A postauricular incision is made for wide expo-
sure. The cartilaginous canal is sectioned at the level
of the mastoid cortex through the postauricular in-
cision (Fig. 8-2/1). An infected stenotic plug of canal
skin is removed using an elevator and curets (Fig. 8-
28). The thin epithelial layer over the tympanic
membrane is also carefully peeled off; this can be
done concurrently with canal skin removal or sepa-
rately. The utmost care must be taken to avoid
perforating the tympanic membrane. If a small tear
occurs the edges are approximated; for larger defects
a fascia graft might be needed (see Chapter 12). The
best treatment is prevention.
The bony canal is enlarged with a cutting bur. The
canal is drilled as much as possible until the entire
tympanic membrane is visible; care must be exercised
not to enter the temporomandibular joint anteriorly
and the mastoid air cells posteriorly.
A meatoplasty is performed by removing the in-
fected narrow meatus and conchal cartilage (Fig. 8-
2C). The anterior cartilaginous canal skin up to the
tragus also can be removed if infected. The meatus
should be large enough to admit a forefinger.
After the infected canal skin and the meatus are
removed and the bony canal wall is smoothed down,
a split-thickness patch of skin of 0 .0 1-in thickness is
harvested from the upper medial surface of the arm
with a Daf'ilva dermatome. It is better to err on the
side of thinness when harvesting since thinner skin
takes better than thicker skin. The harvested skin is
laid on a wooden tongue blade and cut into two
unequal pieces. The larger piece is laid out on the
drumhead and covers from the anterior annulus to
the entire posterior half of the canal; the smaller
piece covers the rest of the anterior half of the canal
(Fig. 8- 2D).
A double packing method is used. The first pack-
ing places strips of Owen's silk and antibiotic-satu-
rated cottons through the postauricular exposure.
Gelfoam saturated in antibiotic solution and "wrung
out" can be used instead of rosebud packing. After
this packing is placed, the excess skin is folded over
the pack and the postauricular incision is closed (Fig.
8- 2E) . Under the operating microscope, the folded
grafted skin is laid over anteriorly toward the tragus
and posteriorly toward the concha. Any excess skin
can be trimmed off. The second pack is placed
endaurally (Fig. 8- 2F) . All raw bone is covered with
skin graft, and a pressure dressing is applied over
the ear. The packs are removed after two weeks.
Crusting may occur for several weeks and requires
meticulous removal and cleansing until definite heal-
ing is achieved.
Stenotic Canal
The external auditory canal may narrow owing to
the presence of scar tissue without infection. This
stenosis can cause conductive hearing loss and sec-
ondary ear canal cholesteatoma.
The operative procedure is similar to that for
exostosis. The posterior canal skin flap is developed
from the bony cartilaginous junction to the annulus,
from the 12 to the 6 o'clock position. The bony canal
is smoothed off with a drill and the skin flap is laid
back. Anteriorly a window-shade flap may be nec-
essary. Packing, dressings, and postoperative care
are the same as for exostosis.
Tumors of the External
Auditory Canal
The external auditory canal may be involved with
benign or malignant tumors. The surgical treatment
152 External Ear Canal Procedures
FIGURE 8- 2.
External Ear Canal Procedi),
of these tumors depends on the type and their
location in the canal.
Aim
To achieve complete removal of the tumor and
restore a normal external auditory canal whenever
possible.
Surgical Steps
1. Biopsy of the tumor.
2. Complete removal of tumor with or without
parotidectomy, mastoidectomy, or temporal bone
resection.
3. Split-thickness skin graft.
4. Packing and closure.
Pitfalls
1. Inadequately excising a malignant tumor.
2. Delaying the diagnosis.
3. Causing unnecessary damage to the tympanic
membrane, ossicles, or temporomandibular joint.
4. Leaking of cerebrospinal fluid after temporal
bone resection.
Operative Procedure
Bi opsy
The location, size, and extent of a tumor in the
external auditory canal should be thoroughly evalu-
ated. If otalgia or bleeding is associated with the
tumor, malignancy should be suspected. New im-
aging techniques such as computed tomography (CT)
or magnetic resonance (MR) are helpful in defining
the extent of the tumor. Biopsy should follow after a
thorough examination under an operating micro-
scope, and can be done under local anesthesia using
a cup-biting forceps (Fig. 8-3/4). If the lesion is small
and has not penetrated to the underlying bone, an
excisional biopsy that includes removal of surround-
ing canal skin should be adequate (Fig. 8- 3B).
Anter ior Canal Tumor s
If benign, the tumor with surround!^
canal wall skin is removed. The
e x c
'
s
i o n ^ ^b""
extended up to the tragus and over th,e
n 6
membrane by denuding the epithelial k " "
m c
drumhead (Fig. 8-3C). The bony canal i ^" i de r i d
with a drill, arid a split-thickness skin gr^f( Q j q j
in thickness from the upper medial arm ;
is used to
cover the exposed bone and the drumht, ,
3D).
, d ( F l
S- *-
If the tumor is malignant, lymph^j.
through Santorini's fissures into the " ,
u
feauriculsr
nodes can be assumed. Adequate exci si r j | i
elude a superficial parotidectomy and
r e r
t \ 0 v ! j 0 j 'u~
anterior canal wall. If a CT scan shows ^
e
has extended anteriorly and medially, t ^ ,
m o r
should include the cartilaginous and bo^ ant'e^'o
11
canal wall, the anterior drumhead, the
lobe of the parotid gland, and the conq . "
l c
'
a
mandible (Fig. 8- 3 E). The facial nerve \ h
y e
e
f
j
whenever possible; if involved with hj . ^ . .
included in the excision and repaired vv-^ _J
graft. The canal defect is covered with a _
, .
s
plit-thick-
ness skin graft.
r
Posterior Canal Tumor s
Benign tumors involving the cart i l agi t \ Q u s
rior canal can e excised with a margin ( p.
U S
If the defect is large, a split-thickness skit\ ,
be used. When a tumor i s i n the posterior l "
m a
y
closer to the tympani c membrane, wid^ aj-eas f
posterior canal.skin with the epithelial l f ye r Qj ^
drumhead can'be removed and a spl i t - t hu; ^n e s s
graft is applied! The posterior canal can be 'j
with a drill before the skin graft is applieq
When a malignant tumor is small a r ^
extended t o tfce drumhead, a complete j j . .
radical mastoidectomy is done. If the t urt | 0 r . ' .
i e
to the drumhead a radical mastoidectomy ; .
o s e
t c i * L L . . . j
l s
done.
If a malignant tumor is extensive and
l r
l v0 l ves he
middle ear or mastoid, a subtotal or total
bone resection may be necessary. "
Subtotal Resection of Temporal Bone
The external auditory canal with s u r r o u r , ^ ^
and bone is removed, leaving the facial r ^r v e m j a c (
The incision i s made anterior and post er, ^ ( q '
auricle, with the inferior extension along tk,e a n t e r o
border of the sternocleidomastoid muscl e p.
4A). The auricle is elevated superiorly, leav;
External Ear Canal Procedures
FIGURE 8-3.
External Ear Canal Procedures 155
FIGURE 8-4.
156 External Ear Canal Procedures
of tissue from the canal and meatus. A wide area of
mastoid cortex is exposed, along with the parotid
gland and the facial nerve as it exits from the stylo-
mastoid foramen. Using the operating microscope
and drill, the entire mastoid portion of the facial
nerve is exposed. The bony canal is isolated and
separated from surrounding structures. Anterosu-
periorly, the bony buttress of the zygomati c process
of the temporal bone is drilled down. Anteriorly, the
capsule of the temporomandibular joint is separated
from the canal wall. The malleus is removed along
with the tympanic membrane; the incus may be left
intact or removed, depending on the extent of the
tumor. Drilling is continued just anterior to the facial
nerve, as in the extended facial recess approach.
Interiorly, the dissection is limited by the jugular
bulb. The specimen is separated as drilling continues
just above the bony annulus (Fig. 8- 4B). After the
specimen is removed, the middle ear space and
exposed dura are covered by a large temporal fascial
graft (Fig. 8- 4C). The fascia is held in place by a
rosebud or Gelfoam pack and the wound is closed.
Total Temporal Bone Resection
After the incision is made, the auricle is elevated
with the superiorly based flap. Wide areas of the
zygomatic arch, the squamous portion of the tem-
poral bone, and the mastoid are exposed by elevating
the temporal muscle (Fig. 8-5, 4). The lower limb of
the incision is made and the parotid gland is exposed.
The internal jugular vein is exposed by detaching the
sternocleidomastoid muscle from the mastoid tip.
The arch of the zygoma is removed and the middle
fossa dura is exposed by drilling on the squamous
portion of the temporal bone; this opening is en-
larged with a rongeur. Elevation of the dura roni
the temporal bone allows the tumor to be evali ated
for possible intracranial extension (Fig. 8- 5B). The
head of the mandible is removed. If the turno. has
invaded the anterior canal, a total paroti dectori y is
done; the facial nerve is resected and the post*rior
belly of the digastric muscle is severed (Fig. 8- 5C).
The internal carotid artery is exposed with a Irill;
during this procedure the bony eustachian tut e is
transected (Fig. 8- 5D). The bone over the internal
carotid artery is removed with the points of the
artery's entrance into the foramen lacerum defining
the anterior and superior limits of the resection i Fig.
8-6 /1). A mastoidectomy is performed, exposing the
sigmoid sinus with a drill (Fig. 8- 6 B). The speciraen
is removed by fracturing the temporal bone thro igh
the otic capsule with a chisel placed just pos t er i c to
the internal carotid artery. Hemorrhage is contro led
with packing. The boundaries of the resection are
the internal carotid artery anteriorly, the middle fossa
dura superiorly, the posterior fossa dura and sigmoid
sinus posteriorly, and the petrous apex medially (f ig.
8- 6 C). The line of resection as seen from abo 'e,
passes through the petrous portion of the tempo'al
bone just lateral to the internal auditory canal. If the
tumor extends to the dura, the involved portion may
have to be resected; if there is evidence of metastasis
to the neck, a radical neck dissection may be neces-
sary. The wound is closed after the defect is filled
with temporal muscle and a large meatoplasty is
done (Fig. 8-6 D). A split-thickness skin graft ov^r
the temporal muscle will shorten the healing time. If
the tumor extends to the auricle, the entire auricle
and its surrounding skin are excised (Fig. 8- 6 E) . The
defect is best covered with a myocutaneous flap fro n
the greater pectoral muscle.
External Ear Canal Procedures
FIGURE 8-5.
FIGURE R-6 .
CHAPTER 9
Congenital Atresia
Congenital aural atresia remains one of the most
challenging (and rewarding) of all otologic problems.
With the eventual incorporation of fully developed
bone conduction aids, the indications for surgery
may vary; it is essential, however, to have a clear
understanding of the main surgical points and con-
cepts. A full discussion of the subject would require
a detailed review of embryology types and forms of
atresia and their surgical indications and timing. This
is outside the scope of this atlas.
The basic requirements for undergoing surgery
include:
1. Pneumatization of the mastoid.
2. Adequate cochlear function.
3. A cooperative patient with a supportive family.
Surgical Technique
Aims
1. To achieve a large meatus.
2. To achieve a self-cleansing mastoid cavity that
can be easily visualized through the meatus.
3. To avoid post-operative stenosis. A large mea-
toplasty, skin grafting of the cavity, and close follow-
up are important favorable factors.
Highlights
1. The middle ear cavity is approached from the
mastoid and not by drilling directly over the atretic
canal.
2. In many patients the temporomandibular joint
is posterior to the auricular remnant. This requires
surgical incisions that allow final positioning of the
ear canal anteriorly to the remnant, and of the
remnant posteriorly to the temporomandibular joint.
Procedure
The Z-plasty technique shown in Figure 9-2A
allows repositioning of the auricle posteriorly and of
the ear canal anteriorly to the auricular remnant.
When the Z-plasty is completed, self-retaining re-
tractors are applied and the mastoid cortex is iden-
tified. This is a crucial point. It is essential to have a
clear anatomi c picture before initiating any drilling.
The linea temporalis usually is identifiable; drilling
is begun anterior to it. The absence of adequate
landmarks can lead the surgeon to explore, and
become lost in, the temporomandibular joint space
without finding the middle ear cavity. This poten-
tially can result in transection of the facial nerve.
Another important precept is that the atretic canal
must not be drilled directly. Pneumatization of the
mastoid is required because the essential procedure
to be done is an open-cavity mastoidectomy, which
allows safe drilling and identification of the facial
nerve, lateral semicircular canal, and middle ear
"from behind" (Fig. 9- 1) . Drilling directly into the
atretic plate carries a significant risk of damaging
these structures. The atretic plate is removed care-
fully while the mastoid drilling is being done (Fig.
9- 2) . A tympanic remnant may or may not be pres-
ent, and the middle ear cavity may be quite small.
Extreme care must be taken not to injure the ossicles,
which may be wholly or partially present, fused, or
absent. Once the ossicles have been identified, their
mobility is assessed and reconstruction of the os-
Congenital Atresia
FIGURE 9 - 1
Congenital Atresia
FIGURE 9 - 2 .
16 2 Congenital Atresia
FIGURE 9- 3.
Congenital Atresia 16 3
FIGURE 9 - 4.
sicular chain is planned accordingly (see Chapter 5) .
The facial nerve not uncommonly is found to have
an abnormal angulation in the second genu, making
a turn of 6 0 degrees rather than 120 degrees (Fig. 9-
3/1). This occurs because the nerve has a smaller
middle ear cleft to encircle; therefore it makes a
sharper angle (6 0 degrees) and exits inferiorly near
the glenoid fossa, in a more lateral position.
Once the mastoidectomy has been performed, the
lateral semicircular canal and facial nerve identified,
the middle ear cavity enlarged, and an ossiculoplasty
done, grafting of the tympanic membrane is per-
formed. Temporal fascia is placed over the recon-
structed ossicles; the fascia must not be excessive, in
order to avoid adhesions and lack of ossicular mo-
bility (Fig. 9-3D). The mastoid cavity itself either is
left "raw" for an eventual Thiersch graft or is grafted
primarily at the same time. The cavity is packed as
described in previous chapters, and the incisions are
closed with appropriate sutures (Fig. 9- 3 E, F ) .
Once again it should be mentioned that a large
meatus is very important; for practical purposes a
meatus can almost never be made too large.
Pertinent Histopathology
FIGURE 9- 4
A horizontal section of the temporal bone of an
individual with congenital atresia and malformation
of the auricle. Mondini's dysplasia also is present.
The magni tude of compromi se is severe. Absence of
the incus, stapes, and oval window can be noted.
The facial nerve also is absent; this can be seen only
in the internal ear canal (not shown here), since the
facial nerve does not course through the temporal
bone.
CHAPTER 10
Surgical
Procedures in
Different Forms of
Otitis Media
Clinical experience and laboratory studies indicate
that middle ear effusions, far from being innocuous,
are slightly delayed reflections of severe underlying
histopathologic changes in the mucoperiosteum.
They are part of a continuum in which some forms
of otitis lead to others, resulting in complications or
sequelae. The immediate purpose of the surgical
procedures described in this chapter primarily is to
halt this process, and to help in the regression of
middle ear histopathologic changes. The ultimate
goal is to arrest the continuum medically, thus re-
serving surgery for the restoration of function rather
than the mere eradication of active disease.
This chapter begins with a description of a myr-
ingotomy and insertion of ventilation tubes. Because
this seems on the surface to be the simplest of
surgical procedures, it can be, and usually is, treated
lightly by surgeons. The procedure is detailed pur-
posely in excess in order to develop a "conscience"
in surgeons about the significance and extreme im-
portance of this "little operati on," which has changed
the course of otologic practice and helped to reduce
significantly the number of major otologic procedures
for complications or sequelae of otitis media. The
chapter concludes with a scries of horizontal sections
of temporal bones, highlighting the underlying
changes in the mucoperiosteum that take place be-
hind an apparently benign "middle ear fluid."
Myringotomy and Tubes
Myringotomy is an incision of the tympanic meri -
brane.
Aim
To substitute f or the function of the eustachian
tubethat is, to provide ventilation and drainage fi r
the middle ear. By providing aeration to the middl ?
ear space, the intent is to reverse the patholog' :
changes of the middle ear mucosa and prevent sub-
sequent complications or sequelae. A myringotomy
also provides symptomati c improvement, confirms i
diagnosis, and allows aspiration of middle ear fluid
(which can also be diagnostic) and insertion of ven-
tilation tubes.
Indications
1. Persistent effusion that has failed to respond tc
adequate nonsurgical therapy.
2. A poorly ventilated middle ear even when fluH \
Surgical Procedures in Different Forms of Otitis Media 16 5
is absent, but the patient is symptomati c or the
tympanic membrane is retracted, or both. A good
and not uncommon example is that of airline pilots
or attendants with eustachian tube dysfunction
(or individuals subjected repeatedly to pressure
changes), who are otherwise asymptomatic.
3. Recurrent otitis media, even when normal con-
ditions exist between episodes.
4. Acute suppurative otitis media with a bulging
or insufficiently perforated tympanic membrane; the
patient is markedly symptomatic. (A myringotomy
alone is performed.)
5. For diagnostic purposes in infants with fever of
unknown origin.
6 . To correct conductive hearing losses due to
effusions.
7. A retracted tympanic membrane before the
stage of atelectasis.
8. With a tympanoplasty in patients with tubal
dysfunction.
9. Otitis media with facial paresis or paralysis or
other impending complications.
Instruments
1. Set of aural specula.
2. Suction tubes (5- , 20 - , and 7-gauge).
3. Myringotomy knife.
4. Baby alligator forceps.
5. Blunt pick (straight or angled).
6 . Small ring curet.
Procedure
First, inspect and visualize (this means to pur-
posefully look and screen and not to glance casually)
the ear canal. Cleanse the cerumen and epithelial
debris very carefully; dry, crusty cerumen can be
washed and loosened with saline or hydrogen per-
oxide. Abrupt cleansing can cause bleeding or small
hematomas in the ear canal. Insert the proper ear
speculum (see Chapter 6 ) and carefully scrutinize the
four quadrants of the tympanic membrane (Fig. 10 -
1/1). Look for perforations, retraction, and retraction
pockets, and for characteristics of the drum itself,
such as myringosclerosis, monomeric areas, atrophic
changes, evidence or suggestion of a dehiscent jug-
ular bulb, evidence of a reddish mass in the anterior
or anteroinferior areas (dehiscent carotid artery), or
myringostapediopexy. Once it becomes a habit, this
inspection does not take time and can avoid a number
of problems. Look first; do the preparatory work;
thenand only thenproceed with the operation.
Initially, a magnification of 6 x will suffice. In
general, the authors tend to use higher power, which
provides a better view of sections of the membrane
(once the area has been inspected and the site of
incision selected).
Incisions
The incision should not be made in the postero-
superior quadrant because of the underlying incu-
dostapedial joint and stapes, nor should it be made
too close to the annulus because this favors early
extrusion of the tube (unless that is the purpose). An
incision should not be made in the presence of acute
infection, again because of the risk of early extrusion
(unless only drainage is intended).
Epithelial migration can be considered for practical
surgical purposes as radiating from the umbo. Mi-
gration is slowest in the anterosuperior quadrant,
followed by the anteroinferior and posteroinferior.
For this reason, the incidence of persistent perfora-
tion is higher in the anterosuperior quadrant. Since
migration is not the only factor in extrusion of the
tubes, the benefits of using this quadrant should be
judged on a case-by-case basis. In addition, surgical
repair of perforations in this quadrant is not so simple
as in other quadrants. The surgeon must decide
whether, in a particular case, a larger flange tube (for
example, a Paparella No. 2) in the anteroinferior or
posteroinferior quadrant would be more beneficial
than a No. 1 tube in the anterosuperior quadrant.
In the middle ear space, incisions should not be
made in the umbo because of its close proximity to
the promontory. The widest space available is the
hypotympanum (Fig. 10 -1B); this must be considered
when there is retraction of the tympanic membrane.
In such a case, incisions in this area allow better
drainage and more space, and carry less risk of
middle ear structural damage.
The length of the incision depends partly on the
type of tube to be used; in general, it should be the
same as the diameter of the inner flange of the tube.
Too short an incision can precipitate tears when the
tube is placed, especially in a weakened or atrophic
membrane (Fig. 10 -2/1). Too long an incision might
preclude a tight fit around the tube, allowing it to
extrude or even fall into the middle ear cavity (Fig.
10 -2B). Paparella-type tubes that have a small inden-
tation in the inner flange can be placed through a
small incision and rotated with baby alligator forceps
or a blunt pick ("screwing motion").
FIGURE 10-1
Surgical Procedures in Different Forms of Otitis Media 16 7
FIGURE 10 -2.
16 8 Surgical Procedures in Different Forms of Otitis Media
A sharp myri ngotomy knife should be used. Inci-
sions can be made radially or circumferentially (Fig.
1U-1C). Circumferential incisions tend to accumulate
more epithelial debris, leading to earlier extrusion of
the tube. In cases of acute purulent otitis a wide
circumferential (smile) incision is preferred, since
drainage alone is the purpose and prompt closure is
desired. In all other circumstances, a radial incision
is preferred, since it sections fewer fibers, runs par-
allel to most of the blood vessels irrigating the mem-
brane, and causes less scarring.
The tip of the knife should be inserted just far
enough to section the membrane; deeper incisions
might damage the middle ear mucosa (Fig. 10 -1D,
). If there is localized bleeding (thicker membranes
sometimes bleed) and blood obscures the incision,
'hydrogen peroxide or cotton saturated with epineph-
rine, or both, will control it.
Tubes
Tubes should be placed in a normal area of the
membrane. Special care should be taken to avoid
atrophic or monomeri c areas. Myringosclerotic areas
tear easily and tubes do not hold well. In contrast,
tubes in normal areas that are surrounded by sclerotic
plaques tend to stay in place for long periods.
Before inserting the tube, as much middle ear fluid
as possible should be removed. Markedly retracted
tympanic membranes tend to have small amounts of
this serous fluid. A No. 5 suction tip can be used,
placed barely through the incision while trying to
avoid enlarging the incision or causing localized
bleeding (Fig. 10 -2C). If the middle ear cavity is to
be entered with a suction tip, the smaller No. 20 is
preferable. Excessive suctioning can also cause mu-
cosal bleeding. With thick mucoid effusions, a No. 5
suction tip may be insufficient. In some cases a baby
alligator forceps, or a No. 7 suction tip placed im-
mediately above (not through) the incision, can be
useful (Fig. 10 -2D). Occasionally a counterincision
that allows air to enter the middle ear cavity while
the fluid is suctioned is helpful. When fluid is not
completely removed by one incision, a small incision
in a different quadrant may be more effective in
removing loculated fluid than "fishing" in the middle
ear cavity with a suction tip. Some authors consider
counterincisions undesirable, but in the authors' ex-
perience a small incision consistently heals well. It is
important to make a clean incision and to approxi-
mate the edges carefully. A small piece of Gelfoam
saturated with a drop or two of blood can be used
to cover the incision. In thick, cloudy mucoid effu-
sions, a No. 2 tube is placed; this tube is also used
in infected effusions with facial palsy. Cultures also
should be obtained in these cases. It is a good habit
to visualize the middle ear mucosa through the
incision.
The canal, the tympanic membrane, and eveo. the
middle ear cavity can be irrigated with salinj anti-
biotic-steroid solutions, or hydrogen peroxide as
needed. When used in the middle ear cavity, anti-
biotic solutions should be neutral (not acid); < ther-
wise there may be considerable postoperative pain
(or intraoperative pain if local anesthesia is used).
Ophthalmic drops are useful. Ototoxic antib.otics
should be avoided.
Types of Tubes
There are many kinds of tubes of different she pes,
sizes, and materials, ranging from "homemade"
polyethylene to Silastic, Teflon, or metal; some ex-
amples are shown in Figure 10 - 2E- G. The type of
tube is less important than the rationale for using it.
In terms of size and shape, three types can be
considered: short -, medi um- , and long-term. L-.mgth
of stay depends partially on the type of tube (except
for permanent tubes, which are described elsevhore
in this chapter). Additional important factors - O c f e d
considered include the quadrant of insertion, c.mcfP
tions of the membrane, and individual tympanic
membrane migration, among others. The au hois
have seen many so-called long-term tubes leid to
eventual perforations requiring tympanoplasty. ! has
also been observed that shorter tubes with wide
lumens tend to plug less and collect less epithelial
debris than long-term tubes protruding from the
tympanic membrane. In general, however, i lost
well-designed tubes work well if they are pror erly
used.
Cost of the tubes is also a factor. Variation * in
price sometimes seem illogical. The authors I ave
designed and used 18-karat gold tubes handmad? in
Chile that are 20 0 % cheaper than the least expen .ive
plastic tube.
Placement of the Tube
With a baby alligator forceps, the tube is grasi ed
gently from its outer border or from a special ip.
The incision should be clean and free of blood. The
inner flange is laid sideways on the incision (proximal
end) (Fig. 10 - 3A). Sometimes it can be "popped" or
"screwed" in with a gentle motion (Fig. 10 - 3 8) .
Usually it can be laid over the proximal lip of the
incision and then pushed in with a blunt pick, either
by pressing it from its superior surface or by gently
FIGURE 10 - 3.
170 Surgical Procedures in Different Forms of Otitis Media
twisting it around (Fig. 10 - 3 C, D) . Once the tube has
been inserted, it is a good idea to rotate it to ensure
that it is in position.
Once it has been verified that the tube is in place,
it is a good idea to place a No. 20 (or smaller if
needed) suction tip through the opening of the tube
(Fig. I 0 - 3 E) . Any middle ear fluid or blood should
be suctioned and a few drops of hydrogen peroxide
left in place. Postoperatively, the authors tend to
recommend neutral pH drops for two or three days
to ensure that patency is maintained. If there is any
pain or discomfort with the drops, they are discon-
tinued. If the fluid is cloudy or shows any signs of
infection, do not hesitate to keep the patient on
antibiotics (and culture the effusion). These appar-
ently small details in technique can make a big
difference in ventilation tube insertion.
Complications
Potential
As in most surgical procedures, the best treatment
for complications is to prevent them. Excessive desire
for speed is a potential surgical enemy, particularly
harmful in tube insertion. Many unnecessary prob-
lems arise in training programs because this "simple
procedure" is left to the most junior and inexperi-
enced surgeons. It takes time to learn how to use an
operating microscope propcrlv and to see all thai
must be seen. Mutual coordination ami understand
ing with the anesthesiologist are essential. I he resi-
dent should ask for help if his or her orientation and
timing are inadequate; the anesthesiologist should
understand that the purpose of the procedure is to
protect the patient's ears, not the ancslhesiologist's
hand.
Intraoperative
1. A small ear canal can make it difficult to visu-
alize the whole tympanic membrane. Extreme care
should be taken to avoid damaging the skin of the
ear canal; bleeding will further obscure vision. A
small ear speculum can be gently "screwed" in, and
the speculum size gradually increased.
2. For lacerations, bleeding, or hematoma of the
ear canal, carefully irrigate with hydrogen peroxide
or apply small cotton balls saturated with epineph-
rine, or both.
3. Facial paralysis due to injection of local anes-
thetics is a temporary phenomenon of no conse-
quence, but the surgeon must be aware of ' lis
annoyi ng possibility.
4. For bleeding from the incision, use hydrogen
peroxide or cotton balls saturated with epinephrine,
or both.
5. If an incision is too long, approximate the
borders carefully; if necessary, place small pieces of
Gelfoam saturated with a few drops of blood and
select a different site for the incision. Large tears and
tears in myringosclerotic areas may require a tym-
panoplasty.
6 . For a too-deep incision causing mucosal bleed-
ing, aspirate fluid and irrigate the middle ear wi h
hydrogen peroxide or a few drops of epinephrine
solution, or both. Use postoperative antibiotic-stero d
drops.
7. If a tube has fallen into the middle ear cavi t/,
carefully recover it through the available incision or
make a new incision if necessary. However, if it is
lost in the cavity, if is better to leave it in or ( rare!')
perform an exploratory tympanotomy than to fich
blindly for it.
8. If bleeding occurs because of damage to a
jugular bulb occupying the hypotympanum (either
in a high location or medial to the tympanic mem-
brane), immediate packing should be done, initially
with Gelfoam and then with tight gauze packing.
The Gelfoam layer helps to avoid further bleeding
when removing the gauze pack. Do not panic, j. st
pack.
4, Damage to the ossicular chain and damage ;o
the facial nerve are uncommonly seen complicatio IS
that reqtiire exploration; they are dealt with in e
1
1-
ferenl chapters.
Postoperative
I Short-term:
A. Inlccted ear drainage (purulent otorrhea) ir .-
mediately after surgery usually means that , n
infected middle ear effusion or silent otil S
media was present. Antibiotics (orally and top-
ically) should be used. The same t reat me'T
should suffice for late purulent otorrhea.
B. Forcing the footplate into the vestibule in CAST 5
of previous myringostapediopexy (either spor -
taneous or postsurgical) has been described
The best treatment here, as for all other com-
plications, is prevention; once it has occurred
exploration is indicated.
C. Otalgia usually occurs with acid otic drops
Neutral drops or ophthalmologic drops usualli
suffice. The value of drops should be assessed
on a case-by-case basis. On occasion, the dis-
Surgical Procedures in Different Forms of Otitis Media 171
comfort is caused by the drops dripping into
the nasopharynx.
2. Long-term:
A. Epithelial debris or cerumen blocking the tube
can be removed with a small hook under the
microscope. It is a good idea to use otic drops
and sometimes hydrogen peroxide to soften
this debris before removal. Occasionally it dis-
solves by itself and can be gently suctioned.
B. Treatment of a permanent perforation of the
tympanic membrane varies. If the patient is a
child with eustachian tube dysfunction and the
perforation is clean and small, it may serve the
purpose of a tube and should be observed
carefully. If the perforation is larger or if the
exposure of the mucosa requires further action,
a tympanoplasty should be done, and possibly
a tube should be placed at another site in the
tympanic membrane.
C. Skin migrating into the middle ear cavity via
the tube opening is a rare event that requires
middle ear exploration, removal of tympanic
membrane edges around the tube, and tym-
panoplasty. On occasion, a congenital choles-
teatoma appears as an apparent complication
of tubes. Adequate preoperative radiologic
evaluation and thorough middle ear explora-
tion are crucial in such cases.
D. Extrusion of the tubes may be followed by
recurrence of the original problems. In some
cases tubes must be reinserted In other cases,
tubes are poorly tolerated or are extruded
shortly alter insertion; these might require
so-called "Iransmeatal permanent aerati on
tubes." The indications are relative and should
be assessed on a case-bv-ease basis. Some
surgeons utilize "permanent" tubes through
the tympanic membrane; these have a high
incidence ol persistent perforation requiring an
eventual tympanoplasty. Transmeatal tubes
are preferred, but the indication for their use
also is relative. The authors do not use per-
manent tubes, preferring instead to reinsert a
No. 2 tube in such cases. Because of their
common use, however, insertion of permanent
tubes is described below.
Transmeatal Permanent
Aeration Tubes
Instrumentation is similar to that for stapedec-
tomy.
Aim
To place a tube beneath the annulus in the pos-
teroinferior quadrant.
Technique (Portmann)
With a curved canal knife, a horizontal incision is
made parallel to the annulus, approximately 10 mm
lateral to it in the posteroinferior quadrant (Fig. 1 0 -
4A). A small flap is elevated and the middle ear
cavity is entered beneath the annulus (Fig. 10 -4B). A
small bur is used to drill a canal in the posterior
bony wall. The tube is placed with the inner flange
medial to the annulus (in the middle ear) (Fig. 10 -
4C). The flap is repositioned and held in place with
Gelfoam and antibiotic-saturated gauze (Fig. 10 -4D).
After one week the gauze is removed.
Complications
1. Those of pressure-equalizing ( PE) tubes.
2. Edema of the skin that obscures the tube.
Treatment with topical antibiotics and steroids usu-
ally solves the problem, allowing the tube to become
visible again.
3. Blockage with debris or cerumen, or both. This
complication is more common with permanent tubes
than with regular tubes. Measures for removal of the
blockage are similar to those lor regular tubes; how-
ever, removal with hooks, requiring a local or general
anesthetic, is more common. (This is equivalent to
reinserting a No. 2 tube.)
In addition, a number of patients over time de-
velop complications or sequelae involving the tym-
panic membrane or middle ear, or both. These in-
clude an atrophic or atelectatic tympanic membrane,
myringosclerosis, chronic otitis media, cholesterol
granuloma, disruption or fixation of the ossicular
chain or tensor tympani tendon, and so on. Such
complications highlight the need for periodic check-
ups and close observation in the treatment of otitis
media. In unresponsive cases or in those in which
underlying middle ear pathology is suspected, there
should be no hesitation in proceeding with explora-
tory tympa lotomy; the surgeon should not sit and
wait for a localized disaster to occur. Exploratory
tympanotomy, tympanoplasty, and ossiculoplasty
are described in different chapters in this book.
Persistent dysfunction of the eustachian tube may
lead to tympanic membrane retraction, thinning, and
Surgical Procedures in Different Forms of Otitis Media
Surgical Procedures in Different Forms of Otitis Media 173
formation of adhesions of the membrane to the
promontory. A tympanoplasty for an atrophic or
atelectatic tympanic membrane (described below)
may be required. On occasion, persistent effusions
and underlying histopathologic changes may lead to
hypocellularity of the mastoid and lack of aeration of
the middle ear cavity. Once these are clinically and
radiologically documented, surgical procedures to
increase aerationeither a mastoidotomy or a cortical
("intact wall") mastoidectomy (described below)
are recommended. Surgery for major complications
of otitis media is described elsewhere in this chapter.
Surgery for an atrophic or atelectatic tympanic
membrane can be performed using a transcanal,
endaural, or postauricular approach. Different meth-
ods can be used; two of the most common, cartilage
tympanoplasty and tympanoplasty for atelectatic
tympanic membrane, will be described. The basic
objectives are (1) to reinforce an exceedingly weak
tympani c membrane, which is usually collapsed and
not uncommonly attached to the medial wall of the
middle ear; (2) to inspect the middle ear cavity, repair
ossicles, and lyse adhesions (re-establishing func-
tion); and (3) to re-establish the middle ear space and
prevent further disease.
These measures, in turn, can be combined with
aeration procedures such as a cortical mastoidectomy
or mastoidotomy. The procedure and approach to
follow depend on the judgment, expertise, and pref-
erence of the surgeon.
A cartilage tympanoplasty will be described as a
transcanal procedure and a tympanoplasty for atelec-
tatic tympanic membrane (adhesive otitis) as an end-
aural approach, with the understanding that they
can be done either way or even by a postauricular
approach. Similarly, a cortical mastoidectomy or a
mastoidotomy can be done by an endaural or post-
auricular approach. It is important for the surgeon
to realize that different approaches can be used
interchangeably or combined as necessary; there are
so many forms of presentation in otitis media that a
"single surgical approach" can be, at times, a very
limiting concept. The two methods described only
suggest alternatives. The surgeon should decide
what is best for the patient and modify these ap-
proaches according to need.
Cartilage Tympanoplasty for
Atrophic Tympanic Membrane
Surgical Steps
1. Transcanal incisions.
2. Tympanomeatal flap.
3. Widening of the bony canal.
4. Harvest i ng t ragus ( cart i lage-peri chondri um
graft).
5. Elevation of the tympanic membrane.
6 . Inspection of the middle ear cavity.
7. Inspection of the antrum and atticotomy-mas-
toidotomy, if necessary.
8. Placement of Silastic, Gelfilm, graft, and PE
tube (optional).
9. Packing and closure.
Highlights
1. Create a large tympanomeatal flap.
2. Carefully harvest and prepare a cartilage-peri-
chondrium graft.
3. Perform a canalplasty.
4. Carefully elevate the thin tympanic membrane.
5. Adequately position the cartilage-perichon-
drium graft.
Procedure
A large tympanomeatal flap is elevated with ver-
tical incisions at 6 and 1 or 2 o'clock (Fig. 10 -5/4). A
large flap is useful since an underlay cartilage-peri-
chondrium graft extending into the posterior canal is
to be used. The posterior canal may need to be
widened. If necessary, the approach can be turned
into a postauricular or endaural approach. If the
posterior canal is not wide enough, the canal wall
can be widened carefully with a bur (after elevating
the flap). If an anterior bony overhang is present, a
window shade is developed and the overhang re-
moved (see Chapter 8). A wide and open canal favors
visualization, postoperative healing, and even hear-
ing (to a small degree).
A cartilage-perichondrium graft is harvested. This
can come from different sources, the most common
being the tragus. An incision is made in the dorsal
(posterior meatal) side of the tragus, and by gentle,
sharp dissection the tragus is isolated and a piece
harvested (Fig. 10 - 5B). The tragus has perichon-
drium on both sides. An incision is made with a
scalpel in one of the borders and the perichondrium
on one side is elevated ( under the microscope) with
a duckbill, leaving the perichondrium as a single
continuous strip with one side attached to the carti-
lage (Fig. 1C-5C). The cartilage can be left as is or
carefully thinned with a scalpel. It can also be com-
pressed briefly and gently; if compressed firmly or for
Surgical Procedures in Different Forms of Otitis Media
FIGURE 10-5.
Surgical Procedures in Different Forms of Otitis Media 175
too long, the cartilage will separate from the peri-
chondrium. The graft is preserved in saline. The
tragal incision is closed with appropriate sutures after
meticulous hemostasis with cautery (or ligation); oth-
erwise, a localized hematoma may develop postop-
eratively.
The tympanic membrane is very carefully elevated
while trying to maintain its integrity. If the mem-
brane has sclerotic plaques, they can be gently and
meticulously removed with a joint knife or its equiv-
alent. It is not imperative to remove all plaques;
excessive removal can cause tears in the membrane.
(To make matters worse, the membrane is poorly
vascularized, so the surgeon must be careful here.)
Any adhesions are carefully sectioned. A No. 20
or 24 suction tip with the finger "off the hole" is
used. The ossicular chain is inspected and, if neces-
sary, reconstructed (see Chapter 12).
If the tympanic membrane is retracted or the
tensor tympani is fixed, or both, the tendon is sec-
tioned. (Fig. 10 -5D). The main aim of this procedure
is to mobilize the malleus and widen the mesotym-
panic space. (This does not produce increased aera-
tion.)
At this point, the attic and antrum are inspected
(Fig. 10 5E). Palpation with a Whirlybird can give a
good idea of the adequacy of communication be-
tween the middle ear and the mastoid antrum. If
there is any question, further inspection is made. It
is not uncommon to find a so-called "aditus block"
that obstructs communication and significantly im-
pairs aeration despite the presence of an adequately
sized mastoid cell system. An atticotomy is done,
the extent of which depends on the degree of visu-
alization needed. The attic is gently curetted down
with stapes curets in a superior to inferior direction
( away from the ossicles), which helps to avoid ossi-
cular disruption. The attic is then inspected, adhe-
sions are sectioned and removed, and the ossicles
are freed of excessive adhesions and connective tis-
sue. If there is any question of insufficient passage,
the mastoid should be inspected. Some authors cre-
ate "observation windows" by drilling openings in
the posterior superior bony canal (over the antrum)
(Fig. 10 - 5f )- Others advocate the use of mirrors.
While these methods are acceptable and work well,
the authors prefer a complete inspection that at the
same time provides a solution. This is achieved by a
mastoidotomy (see Chapter 7) , which provides direct
visualization, ease of cleansing, and removal of any
blocks; increases aeration; and permits irrigation of
the mastoid and middle ear (Fig. 1 0 - 6 4) . An anti-
biotic-steroid solution should flow freelv between
these two cavities. On occasion, a small strip of thin
Silastic can be placed between the antrum and middle
ear to ensure patency. If a wider communication is
needed, a mastoidectomy and a facial recess opening
could be helpful, but usually this is not the case in
the types of problems discussed here. If the mastoid
is found to be involved with disease, a mastoidec-
tomy is done.
Once the ossicles are reconstructed, communica-
tion of the middle ear and mastoid is ensured, and
aeration is felt to be adequate, a thin Silastic sheeting
is placed that extends from the eustachian tube to
the tympani c sinus and round window niche (Fig.
10 -6 B). The cartilage-perichondrium graft is laid over
a piece of Gelfilm, which is placed over the long
process of the incus under the tympanic membrane
(Fig. 10 - 6 C). The perichondrium that is not attached
to cartilage is placed over the posterior canal wall
(Fig. 10 -6 D). This type of graft also is very useful in
covering atticotomy defects, and in areas where re-
traction pockets tend to occur or recur. It is an easy
and very effective resource for ear surgery.
A slightly thicker anterior tympanic membrane
remnant usuplly is present, through which a No. 1
ventilation tube can be inserted (Fig. 10 6 E). The
authors prefer to do this since it helps to ensure
postoperative aeration and healing of the middle ear.
The flap is then repositioned covering the graft, and
the ear canal ss packed. If endaural or postauricular
incisions were used, they are closed in layers and a
dressing is applied.
Tympanoplasty for Atelectatic
Tympanic Membrane
(Adhesive Otitis)
Surgical Steps
1. Endaural incisions ( Lempert 1 and 11).
2. Harvesting of temporal fascia.
3. Tympanomeatal flap.
4. Widening of the bony canal.
5. Elevation of the tympanic membrane.
6 . Repair of ossicles.
7. Inspection of the antrum.
8. Placement of Silastic, Gelfilm, underlay fascia,
and pharyngoesophageal tube.
9. Packing and closure.
Surgical Procedures in Different Forms of Otitis Media 177
Highlights
1. Create a large tympanomeatal flap.
2. Perform a canalplasty.
3. Carefully elevate the thin tympanic membrane.
4. Section the tensor tympani tendon.
Procedure
Endaural incisions ( Lempert I and II) are made.
Using two-prong self-retaining retractors, temporal
fascia is harvested via the Lempert II incision, placed
in Ringer's solution, and pressed for two to three
minutes before being used (Fig. 10 -7. 4). A tympan-
omeatal flap is elevated with vertical incisions at 6
and 1 o'clock; a large flap is best since a large
underlay fascia will be placed extending into the
posterior canal. The posterior canal wall is widened
carefully with a bur (Fig. 10 -7B). If an anterior bony
overhang is present, a wi ndow shade is developed
and the overhang is removed (see Chapter 8). The
canal should be wide and open. This is true for all
middle ear reconstructive procedures except for some
cases of stapedectomy.
The thin tympanic membrane is very carefully
elevated; an attempt should be made to maintain its
integrity. Meticulous sectioning of adhesions is the
key to this elevation. A No. 24 suction tip with the
finger "off the hole" is used. The field should be as
dry as possible; any bleeding is treated with cotton
saturated in epinephrine solution.
The ossicular chain is inspected. Necrosis of the
lenticular process often is found; if so, the area is
reconstructed. If tympanosclerosis is fixating the os-
sicles, this also is corrected (see Chapter 12).
Fixation of the tensor tympani tendon, including
the cochleariform process, is a common finding and
requires a tympanoplasty. The tendon is severed,
which mobilizes the malleus and widens the meso-
tympanic space (Fig. 10 - 7C). If the malleus adheres
to the promontory, the adhesions are freed. If nec-
essary, the distal tip of the long process of the
malleus is severed after being carefully separated
from the overlying tympanic membrane (Fig. 10 -7D).
At this point the attic and antrum should be in-
spected (as discussed in the previous procedure for
an atrophic tympanic membrane).
Once the ossicles have been reconstructed and the
tympanic membrane has been elevated, a piece of
thin Silastic sheeting is placed extending from the
eustachian tube to the tympanic sinus and round
wi ndow niche (Fig. 10 - 7E) . Gelfilm that was kept in
Ringer's solution for softening is placed above the
ossicles between the eustachian tube and the facial
recess (Fig. 10 -8/1), and the fascia is placed beneath
the thin tympanic membrane (Fig. 10 -8C). Usually a
slightly thicker anterior tympani c membrane remnant
is present through which a No. 1 ventilation tube
can be inserted (Fig. 10 -8D). ( Some surgeons thread
a small piece of synthetic nonabsorbable suture
through the tube and into the canal in order to avoid
plugging of the tube with packing and debris. The
authors have not observed plugging to be a problem
in these cases. ) The ventilation tube helps ensure
postoperative aeration and healing of the middle ear.
The ear canal is packed, the Lempert II incision is
closed in two layers, and a mastoid dressing is
applied.
Figure 10 - 9 depicts three alternative methods for
improving aeration of the middle ear.
Mastoid and Tympanomastoid
Procedures in Otitis Media
If intractable disease develops in the mastoid and
middle ear cavity, more extensive surgical procedures
are necessary. These may range from a cortical mas-
toidectomy to a tympanomastoi dectomy and even a
radical mastoidectomy. The comments below are
intended to contribute to the overall concepts of
specific procedures; a complete discussion of specific
indications for;these surgical alternatives is beyond
the scope of this atlas.
The basic aims of mastoid surgery for chronic,
medically intractable otitis media cannot be empha-
sized enough. The first is the eradication of disease;
the second is functional reconstruction.
Both endaural and postauricular incisions and
their corresponding approaches have already been
described. It should be mentioned that if a mastoid
obliteration procedure is planned, a postauricular
incision is made far behind (posterior to) the sulcus
preparatory to the use of a muscle flap (described
below). Although the authors tend to prefer post-
auricular approaches for tympanomastoid surgery,
the endaural approach provides easy access to the
middle ear and mastoid, and is very useful in revision
surgery as well. It can be limited in exposure poste-
riorly in cases of large, well-pneumatized mastoid
cavities.
It is useful to describe the alternative approaches
in mastoid surgery. The simple mastoidectomy
(which derives its name from its original use for
simple drainage and not from the simplicity of the
procedure) was described in Chapter 7; it involves
FIGURE 10 -7.
S ur gi c a l P r o c e dur e s i n Di f f e r e nt F o r ms o f Ot i t i s Me di a
FIGURE 10 -8.
1
5ur gi c a l P r o c e dur e s i n Di f f e r e nt F o r ms o f Ot i t i s Me di a 1 8 1
o pe ni ng t h e ma s t o i d a nd e x e nt e r a t i ng al l ai r c e l l s .
Th i s a ppr o a c h c a n b e us e d f or pur po s e s o f a e r a t i o n
o r r e mo v a l o f di s e a s e , s uc h a s i n a c ut e c o a l e s c e nt
ma s t o i di t i s . I t do e s no t i nvo l ve e nt e r i ng t h e mi ddl e
ear , e x c e pt wh e n c o mb i n e d wi t h a f aci al r e c e s s a p-
pr o a c h ( po s t e r i o r t y mp a n o t o my ) . T h e f aci al r e c e s s
a ppr o a c h a l l o ws e x pl o r a t i o n o f t h e mi ddl e e a r a nd
r e mo v a l o f di s e a s e d t i s s ue ; h o we v e r , i t mus t be ke pt
i n mi nd t h a t i n c a s e s o f c h r o ni c e a r di s e a s e t h i s
a c c e s s o f t e n i s l i mi t e d a nd r e mo v a l o f di s e a s e d mu-
c o s a ma y b e - i nc o mpl e t e . Ne v e r t h e l e s s , t h i s c a n be a
ve r y us e f ul a ppr o a c h , d e p e n d i n g o n wh a t t h e s ur -
ge o n wa n t s t o a c h i e v e i n a s pe c i f i c c a s e .
S i nc e c h r o ni c ot i t i s i nv o l v e s b o t h t h e mi ddl e e a r
a nd ma s t o i d, i t i s of t e n ne c e s s a r y t o di r e c t l y a ppr o a c h
b o t h c a v i t i e s ; h e n c e t h e t e r m t y mp a n o ma s t o i d e c -
t o my . I f t h e po s t e r i o r c a na l wa l l i s l eft i nt a c t a nd
b o t h c a vi t i e s a r e e nt e r e d i nde pe nde nt l y , t h e pr o c e -
dur e i s t e r me d " c a na l wa l l u p , " "i nt a c t c a na l wal l
ma s t o i d e c t o my , " o r " c l o s e d- c a v i t y t y mp a n o ma s t o i d -
e c t o my . " I nt a c t c a na l wa l l pr o c e dur e s a r e pr e f e r a bl e
s i nc e t h e y pr e v e nt a n o pe n ma s t o i d c a vi t y . T h e y
s h o ul d be pe r f o r me d i f t h e r e i s a g o o d po s s i bi l i t y of
e r a di c a t i o n o f di s e a s e ( t h e f i r s t a i m o f ma s t o i de c -
t o my ) a nd i f t h e ma s t o i d i s s uf f i c i e nt l y pne uma t i z e d
t o a l l o w a s a f e pr o c e dur e . A s c l e r o t i c ma s t o i d pr e -
s e nt s a s e r i o us r i s k of c o mpl i c a t i o ns . I n t h e s e c a s e s ,
a t y mp a n o ma s t o i d pr o c e dur e i s no t r e c o mme n d e d
unl e s s t h e o t o l o gi s t i s e x t r e me l y f a mi l i a r wi t h t h e
a ppr o a c h , i t s r i s ks , a nd its l i mi t a t i o ns . Us e of a " c a na l
wal l u p " o r "c a na l wa l l d o wn " a ppr o a c h wi l l d e p e n d
upo n e a c h i ndi vi dua l c a s e . T h e pr i ma r y ai m o f t h e
pr o c e dur e i s t o e r a di c a t e di s e a s e , no t t o ma i nt a i n a n
i nt a c t po s t e r i o r c a na l wa l l . I n o t h e r wo r ds , wh a t
s h o ul d b e d o n e i s wh a t t h e pa t i e nt ne e ds a nd not
wh a t t h e s ur ge o n wo ul d l i ke t o do . Fo r pr a c t i c a l
pur po s e s , t h i s pr o c e dur e wi l l be de s c r i b e d a s a n
e nda ur a l a ppr o a c h .
P r o c e dur e s t hat i nv o l v e r e mo v a l o f t h e po s t e r i o r
c a na l wa l l a r e k n o wn a s "c a na l wal l d o wn " o r " o pe n-
c a v i t y " ma s t o i de c t o mi e s . T h e y i nc l ude t h e B o n d y
pr o c e dur e , t h e i nt a c t - br i dge t y mp a n o ma s t o i d e c -
t o my , t h e mo di f i e d r a di c a l ma s t o i de c t o my , a nd t h e
r a di c a l ma s t o i de c t o my . T h e pr o c e dur e o r i gi na l l y de -
s c r i b e d b y Bo n d y i s i ndi c a t e d o nl y f or a n unus ua l
c a s e o f pr i ma r y c h o l e s t e a t o ma , a nd i nv o l v e s "e x t e r -
i o r i zi ng" t h e c h o l e s t e a t o ma wh i l e pr e s e r v i ng t h e
i nne r ma t r i x o r c a ps ul e . T h e po s t e r i o r b o n y c a na l
wa l l i s r e mo v e d , but t h e mi ddl e e a r c a vi t y i s no t
e nt e r e d. T h e mo di f i e d r a di c a l ma s t o i d e c t o my in-
v o l v e s e nt r a nc e i nt o t h e mi ddl e e a r c a vi t y , a l l o wi ng
t y mp a n o p l a s t y pr o c e dur e s . T h e i nt a c t - br i dge t y m-
p a n o ma s t o i d e c t o my i s a c o n t e mp o r a r y v e r s i o n of t h e
mo di f i e d r a di c a l pr o c e dur e i n wh i c h a b r i dge of b o n e
i s l eft wh e n t h e po s t e r i o r c a na l wa l l i s r e mo v e d; t h i s
a l l o ws mo r e e f f e c t i ve t y mpa no pl a s t y ( r e c o ns t r uc t i o n;
pr o c e dur e s . Fi na l l y , t h e r adi cal ma s t o i de c t o my i s t he
s a me a s a mo di f i e d r a di c a l ma s t o i de c t o my , wi t h t h e
a ddi t i o n o f r e mo v a l o f mi ddl e e a r mu c o s a a nd o s s i -
c l e s ( e x c e pt i ng t h e s t a pe s ) , a nd c l o s ur e ( pl uggi ng) o f
t h e e us t a c h i a n t ube . T h e ma s t o i d a n d mi ddl e e a r
b e c o me a n o p e n ( e x t e r i o r i ze d) c a v i t y wi t h , o b v i o us l y ,
a l o s s of h e a r i ng
Cortical Mastoidectomy
A c or t i c a l ma s t o i d e c t o my wi t h or wi t h o ut a facial
r e c e s s a p p r o a c h ( po s t e r i o r t y mp a n o t o my ) h a s b e e n
de s c r i b e d i n de t a i l a n d wi l l not be r e pe a t e d h e r e .
S uf f i c e i t t o me n t i o n t h a t dr i l l i ng s h o ul d be d o n e
c a r e f ul l y i n t h e p r e s e n c e o f di s e a s e d t i s s ue , s i nc e
c o mpl i c a t i o ns a r e e a s i l y c a us e d. T h e us e o f c ur e t s t o
unr o o f ma s t o i d c e l l s t h a t a r e full o f gr a nul a t i o n t i s s ue
i s a g o o d a n d s a f e h a b i t , e s pe c i a l l y wh e n t h e r e a r e
do ub t s a s t o t h e unde r l y i ng s t r uc t ur e s . I f i n do ub t ,
pa l pa t e t h e ai r c e l l wi t h a Wh i r l y b i r d a nd t h e n c ur e t .
S pe c i a l c o ns i de r a t i o ns i n ma s t o i d pr o c e dur e s a r e
de s c r i b e d e l s e wh e r e i n t h i s c h a pt e r . F o r a n ove r a l l
v i e w o f t h e s e c a s e s , i t i s r e c o mme n d e d t ha t t h e e nt i r e
c h a pt e r b e r e a d, not j us t i ndi vi dua l a ppr o a c h e s .
Closed-cavity
Tympanomastoidectomy
I nc i s i o ns a r e ma d e wi t h a s c a l pe l , a nd e x po s ur e i s
i mpr o v e d by us i ng a c ur v e d na s a l s pe c ul um. T h e
first i nc i s i o n L e mp e r t 1) i s ma d e s e mi c i r c umf e r e n-
tial l y b e t we e n 6 a nd 12 o ' c l o c k on t h e po s t e r i o r wa l l
a t t h e b o n y c a r t i l a gi no us j unc t i o n. T h e s e c o nd i nci -
s i on ( L e mpe r t II) r uns b e t we e n t h e t r a gus a nd h e l i x
a nd i nc i s ur a ; t h e e x t e nt o f t h i s i nc i s i o n d e p e n d s upo n
t h e de g r e e o f - ' x po s ur e o f t h e ma s t o i d ne e de d, but a
l e ngt h o f 0. 7 5 c m i s no t u n c o mmo n . T e mp o r a l f as ci a
i s h a r v e s t e d t h r o ugh t h i s i nc i s i o n f or gr a f t i ng pur -
po s e s . T h e r e ma i ni ng po s t e r i o r c a na l s ki n ( car t i l agi -
no us po r t i o n) i s pr e s e r v e d a nd ge nt l y e l e v a t e d wi t h
a s ma l l pe r i o s t e a l e l e v a t o r , l e a vi ng t h e wh o l e po s t e -
r i or b o n y c a na l c l e a r l y e x p o s e d , ( On o c c a s i o n, a s ma l l
fr ee s ki n gr af t c a n be r e mo v e d s a f e l y f r om t h i s a r e a . )
T h e s pi ne o f He n l e i s i de nt i f i e d a nd t h e pe r i o s t e um
e l e v a t e d of f t h e ma s t o i d, e x po s i ng its l a t e r a l s ur f a c e
( c o r t e x ) i n i t s e nt i r e t y f r o m t he t e mpo r a l l i ne ( l i ne a
t e mpo r a l i s ) s upe r i o r l y t o t h e ma s t o i d t i p i nt e r i o r l y
T h r e e - pr o ng s e l f - r e t a i ni ng r e t r a c t o r s a r e us e d. I t
i s h e l pf ul t o po s i t i o n t h e m a t r i ght a ng l e s t o o ne
S ur gi c a l P r o c e dur e s i n Di f f e r e nt F o r ms o f Ot i t i s Me d i a 183
a no t h e r , wi t h o n e po i nt i ng c e ph a l a d ( s upe r i o r l y ) a nd
o ne c a uda d ( po s t e r i o r l y ) ( Fi g. 1 0- 1 0/ 1 ) . S c h u k n e c h t
r e t r a c t o r s a l l o w wi de r e x po s ur e t h a n Wul l s t e i n r e-
t r a c t or s i n t h e s e c a s e s . At t h i s po i nt , t h e ma s t o i d
a nd e a r c a na l a r e we l l e x p o s e d .
If n e e d e d f or e x po s ur e , a c a na l pl a s t y ( pr e v i o us l y
de s c r i b e d) i s do ne , a nd t h e e nt i r e f i br o us a n d b o ny
a nnul us i s e x p o s e d wi t h o ut e nt e r i ng t h e t e mpo r o -
ma ndi b ul a r j o i nt s pa c e .
Wi t h t h e s c a l pe l , i nc i s i o ns c a n be ma d e a t 6 a nd 1
or 2 o ' c l o c k. T h e s e i nc i s i o ns a l l o w f or e a s i e r de v e l -
o p me n t o f t h e f l a p; h o we v e r , t h e f l ap c a n b e e l e v a t e d
wi t h o ut t h e s e i nc i s i o ns . Af t e r t h e mi ddl e e a r c a vi t y
i s e nt e r e d ( b e ne a t h t he a nnul us ) , t h e a di t us i s e n-
l a r ge d s o t h a t t h e i nc us i s r e a di l y s e e n, a l l o wi ng
i ns pe c t i o n o f t h e e p i t y mp a n u m t h r o ugh t h e a di t us
a d a n t r um ( Fi g. 1 0 - 1 0 B ) . T h e t e c h ni que o f a ma s t o i d-
e c t o my h a s b e e n de s c r i b e d. Co r t i c a l wh i t e b o ne
s h o ul d be o b t a i ne d i n al l di r e c t i o ns , but s a uc e r i za t i o n
of t h e o ut e r c o r t e x i s no t s o i mpo r t a nt a s i n a
c o mpl e t e ma s t o i d e c t o my s i nc e t h e r e i s no r e s i dua l
o p e n c a vi t y . T h e s a me pr i nc i pl e s de s c r i b e d f or ma s -
t o i de c t o my a s a n a ppr o a c h a ppl y h e r e . Ho we v e r ,
s o me i mpo r t a nt po i nt s r e l a t i ve t o c h r o ni c ot i t i s
s h o ul d b e me n t i o n e d .
1. I n c a s e s i n wh i c h t h e ma s t o i d i s full of i nf l a m-
ma t o r y t i s s ue , t h e s ur ge o n c a n e a s i l y l o s e mo me n -
t ar i l y t h e s e n s e o f de pt h a nd l oc a t i on o f t h e a nt r um.
S i nc e t h e mi ddl e e a r i s c l e a r l y e x po s e d, a Wh i r l y b i r d
c a n b e i nt r o duc e d i nt o t h e a nt r um vi a t h e mi ddl e e a r
s i de a nd vi s ua l i ze d or pa l pa t e d t o h e l p r e ga i n s ur gi c a l
o r i e nt a t i o n.
2. I nf l a me d t i s s ue mus t be r e mo v e d c a r e f ul l y , i n
a s t e p- b y - s t e p f a s h i o n ( Fi g. 1 0 - 1 0 C) . Do no t " pul l "
l a r ge pi e c e s o f t i s s ue o r dr il l i nt o " h o l e s . "
3 . S pe c i a l a t t e nt i o n s h o ul d b e gi v e n t o i de nt i f y i ng
t h e l o c a t i o n of t h e facial ne r v e a t al l l e ve l s . I t s b o ny
c a na l ma y b e e r o de d ( e x po s i ng t h e ne r v e ) o r t he
ne r v e ma y be o ut o f its us ua l a na t o mi c po s i t i o n, o r
bo t h .
4. Cl e a n s i n g o f all di s e a s e d t i s s ue i n t h e a r e a o f
t h e f aci al r e c e s s ( s upr a py r a mi da l r e c e s s ) a nd t he
t y mp a n i c s i nus ( i nf r a py r a mi da l r e c e s s ) s h o ul d b e
t h o r o ugh ( Fi g. 1 0 - 1 0 D ) . T h e s ur ge o n mus t b e e s pe -
ci al l y c a r e f ul i n c l e a ns i ng t h i s a r e a ; t h i s i s a c o mmo n
s i t e f or i a t r o ge ni c i nj ur y t o t h e f aci a! ne r v e . Wi t h t h i s
s ur gi c a l a ppr o a c h , r e mo v a l o f di s e a s e d mu c o s a i n
t h i s a r e a s o me t i me s i s di f f i cul t .
5. Os s i c l e s s h o ul d be c a r e f ul l y c l e a ns e d o f di s e a s e d
mu c o s a ( Fi g. 1010) . I t i s c r uc i a l t o a v o i d bo t h
di s l o c a t i o n o f t h e o s s i c ul a r c h a i n ( or its r e mna nt s )
a nd r e mo v a l o r di s l o c a t i o n o f t h e s t a pe s , wh i c h
wo ul d h a v e o b v i o us l y c a t a s t r o ph i c c o n s e q u e n c e s for
h e a r i ng. I f t h e s t a pe s i s a c c i de nt a l l y r e mo v e d , t h e
ova l wi n d o w i s s e a l e d wi t h c o l l a ge n t i s s ue a nd c o v -
e r e d wi t h Ge l f o a m s a t ur a t e d i n a nt i bi o t i c s o l ut i o n.
6. I n s ur ge r y ( or c h r o ni c e a r di s e a s e , t h e s ur ge o n
s h o ul d gi v e s pe c i a l a t t e nt i o n a n d c a r e t o t h r e e a r e a s
o r s t r uc t ur e s : t h e f aci al ne r v e , t h e h o r i zo nt a l s e mi c i r -
c ul a r c a na l , a n d t h e s t a pe s ( Fi g. 1 0 - 1 1 ) . T h e s e a r e a s
r e qui r e e a r l y a n d c l e a r i de nt i f i c a t i o n dur i ng t h e pr o-
c e dur e a nd v e r y c a r e f ul ma n a g e me n t wh e n i nv o l v e d
wi t h di s e a s e .
7. I t i s unwi s e t o r e mo v e t o o mu c h of t h e a t t i c
wa l l f or p u r p o s e s o f e x po s ur e ; t h i s ma y r e s ul t i n a
po t e nt i a l r e t r a c t i o n po c ke t a r e a . I f t h i s o c c ur s , a
c a r t i l a ge - pe r i c h o ndr i um gr af t ( de s c r i b e d e a r l i e r i n
t h i s c h a pt e r ) c a n b e pl a c e d t o c o v e r t h e de f e c t .
8 . Ch o l e s t e a t o ma s a nd gr a nul a t i o n t i s s ue h a v e t h e
c a pa c i t y t o e r o de b o n e a nd r e s ul t i n fistul a f o r ma t i o n.
T h e r e i s no a g r e e me n t a s t o t h e ma n a g e me n t o f t h e s e
f i s t ul a e . I n ge ne r a l , wh e n a c h o l e s t e a t o ma e r o de s t h e
p r o mo n t o r y t h e ma t r i x ( c a ps ul e ) s h o ul d be l eft i n
pl a c e , o wi n g t o t h e h i gh f r e que nc y o f t ot al h e a r i ng
l o s s a s s o c i a t e d wi t h i t s r e mo v a l . I f a f i s t ul a of t h e
( s ma l l ) h o r i zo nt a l s e mi c i r c ul a r c a na l e x i s t s wi t h no
a ppa r e nt i nv o l v e me nt o f t h e unde r l y i ng me mb r a -
n o us l a b y r i nt h , t h e ma t r i x c a n b e r e mo v e d . Ve r y
ma n y f i s t ul a e a r e i de nt i f i e d i n s ur ge r y f or wh i c h
t h e r e we r e no pr e o pe r a t i v e s y mp t o ms o r di a gno s t i c
s us pi c i o ns b a s e d o n l a bo r a t o r y s t udi e s .
9 . O n c e a ga i n, t h e pr i ma r y a i m o f t h e s e pr o c e -
dur e s i s t o e r a di c a t e di s e a s e . Re c o ns t r uc t i o n i s t h e
s e c o nd a i m a nd wi l l be de s c r i b e d i n Ch a pt e r 12.
Ma i nt a i ni ng t h e po s t e r i o r c a na l wa l l i nt a c t i s no t a n
a i m; i t i s a pr e f e r e nc e i f c o ndi t i o ns a l l o w i t t o be
d o n e s a f e l y a nd pr o pe r l y .
Cl o s ur e a nd t h e t e c h ni que o f me a t o pl a s t y h a v e
a l r e a dy b e e n de s c r i b e d.
Intact-bridge
Tympanonnstoidectomy (IBM)
Th i s pr o c e dur e i s de s c r i b e d h e r e a s a po s t a ur i c ul a r
a ppr o a c h . Its a i ms wi l l be l i s t e d a nd t h e ba s i c s t e ps
o nl y t o uc h e d u p o n s i nc e t h e y h a v e b e e n de s c r i b e d
e a r l i e r ( s e e Ch a p*e r 5) . T h e s a me pr i nc i pl e s a s f or a
c l o s e d- c a v i t y t y mp a n o ma s t o i d e c t o my f or c h r o ni c ot i -
tis me di a a ppl y t e r e . As di s c us s e d pr e v i o us l y , dif-
f e r e nt s ki n f l a ps c a n be us e d a Ko r ne r ' s f l ap or a
f l ap ma d e by a n i nc i s i o n i n t h e po s t e r i o r c a na l wa l l
s ki n a t t h e b o n y c a r t i l a gi no us j unc t i o n. T h i s i nc i s i o n
c a n be ma d e wh e n t h e po s t a ur i c ul a r f l ap i s l i f t ed, o r
t h r o ugh t h e c a na l b e f o r e l ifting t h e f l ap.
184 S ur gi c a l P r o c e d ur e s i n Di f f e r e nt F o r ms o f Ot i t i s Me d i a
FI GURE 10-11
r
S ur gi c a l I r o c e dur e s i n Di f f e r e nt F o r ms o f Ot i t i s Me d i a 185
Aim
To e xt e r i o r i ze t h e di s e a s e pr o c e s s wi t h i n t h e epi -
t y mp a n u m, a nt r um, a n d ma s t o i d t o t h e me a t us . T h e
I BM i s a c o n t e mp o r a r y v e r s i o n o f t h e mo di f i e d r a di c a l
ma s t o i d e c t o my wi t h b r i dge pr e s e r v a t i o n, a l l o wi ng a
b e t t e r t y mpa no pl a s t y r e pa i r .
Highl ights
1. Enl a r g e t h e a nt e r i o r c a na l wa l l wi t h o ut o pe ni ng
t h e t e mp o r o ma n d i b u l a r j o i nt , a nd v i s ua l i ze t h e e nt i r e
f i br o us a n d b o n y a nnul us .
2. P e r f o r m a l a r ge me a t o pl a s t y ; t h i s i s c r uc i a l f or
t h e s uc c e s s o f t h e pr o c e dur e .
Pitfalls
1. I nc o mpl e t e l y r e mo v i n g t h e po s t e r i o r me a t a l
wa l l . -
2. P e r f o r mi ng a po o r me a t o pl a s t y .
Surgical Steps
1. Me a t o pl a s t y .
2. Ca na l pl a s t y .
3. Ci r c umf e r e nt i a l s a uc e r i za t i o n o f t h e ma s t o i d.
4 . En l a r g e me n t o f t h e a di t us a nd s c ul pt ur i ng o f
t he b r i dge t o wi de n t h e me s o t y mp a n u m.
5. Re mo v a l of al l di s e a s e .
6 . P r e s e r v a t i o n, wh e n po s s i b l e , o f t h e a nt e r i o r
t y mpa ni c me mb r a n e a nd ma n u b r i u m.
7. Us e of a ve nt i l a t i o n t ube .
8. Os s i c ul o pl a s t y , t y mpa no pl a s t y
9. Ob l i t e r a t i o n o f t h e a di t us wi t h pe r i o s t e um o r
c a r t i l a ge .
10. Ma s t o i d o bl i t e r a t i o n ( us ua l l y no t ne c e s s a r y ) .
11. T h i e r s c h gr a f t ( t h r e e t o f o ur we e k s po s t o pe r -
a t i ve l y ) .
Procedure
Th i s pr o c e dur e i nv o l v e s r e mo v a l o f t h e po s t e r i o r
me a t a l wa l l wi t h pr e s e r v a t i o n o f t h e " b r i d g e . "
Ex po s ur e o f t h e ma s t o i d c o r t e x wi t h a po s t a ur i c -
ul ar a ppr o a c h h a s a l r e a dy b e e n de s c r i b e d. T h e t y pe
of f l ap t o be us e d i s s e l e c t e d a nd a ppr o pr i a t e i nc i s i o ns
ar e ma d e ( Fi g. 1 0 - 1 2 , 4 ) . Th i s i s f o l l o we d by a me a -
t o pl a s t y ( s e e Ch a p t e r 7) a nd a c a na l pl a s t y , unt i l t he
e nt i r e f i br o us a nd b o n y a nnul us i s f ul l y vi s ua l i ze d
wi t h o ut e nt e r i ng t h e t e mp o r o ma n d i b u l a r j o i nt s pa c e
( Fi g. 1 0 - 1 2 B - E ) . T h i s i s t h e t i me t o t r i m a n d
" f r e s h e n" t h e e dg e s ( i f ne c e s s a r y a nd i f po s s i b l e ) o f
a pe r f o r a t e d t y mpa ni c me mb r a n e .
T h e ma s t o i d wo r k i s n o w b e gun; Fi gur e 1 0- 1 3 / 4
s h o ws t h e s i t e o f t h e o p e n i n g t o b e ma de . I n t h e s e
c a s e s , t h e s ur g e o n us ua l l y i s de a l i ng wi t h s c l e r ot i c
s ma l l ma s t o i ds ( l a r ge , we l l - pne uma t i z e d ma s t o i ds
l e nd t h e ms e l v e s b e t t e r t o i nt a c t c a na l wa l l pr o c e -
dur e s ) . Fi gur e 1 0 - 1 3 B , C s h o ws t h e r e mo v a l o f di s -
e a s e d t i s s ue f r om t h e ma s t o i d a nd a nt r um. I t i s
i mpo r t a nt t o s a uc e r i ze t h e e dg e s ( Fi g. 1 0 - 1 3 D ) , s i nc e
t h i s l e a ds t o a s ma l l e r c a v i t y a nd f r e que nt l y ma k e s i t
unne c e s s a r y t o o bl i t e r a t e t h e c a vi t y wi t h mus c l e
( ma s t o i d o bl i t e r a t i o n pr o c e dur e s a r e de s c r i b e d be -
l o w) . Th i s ma s t o i d e c t o my i mpl i e s l e a v i ng t h e
" b r i d g e " i nt a c t ( Fi g. 1 0 - 1 3 E) . T h e b r i dge i s t h e mo s t
me di a l po r t i o n o f t h e po s t e r o s upe r i o r me a t a l wa l l ,
a nd c r o s s e s t h e a t t i c t o wa r d t h e t e g me n . I t h a s b o t h
a nt e r i o r a nd po s t e r i o r b ut t r e s s e s . T h e a nt e r i o r but -
t r e s s i s t h e s upe r i o r po r t i o n wh e r e t h e po s t e r i o r b o ny
c a na l me e t s t h e t e g me n; t h e po s t e r i o r b ut t r e s s i s t h e
i nf e r i or po r t i o n wh e r e t h e po s t e r i o r b o n y c a na l me e t s
t h e f l oor o f t h e e x t e r na l a udi t o r y c a na l , l at er al t o t h e
facial ne r v e ( Fi g. \0-\4A-C).
On c e di s e a s e d t i s s ue h a s b e e n r e mo v e d , a n o s s i c -
ul o pl a s t y i s do ne ; F i gur e 1 0 - 1 4 D , E a n d Fi gur e 1 0 -
15 s h o w pr e pa r a t i o n f or a n d pl a c e me nt o f a par t i al
o s s i c ul a r r e pl a c e me nt pr o s t h e s i s ( P O R P ) . A t ub e i s
t h e n pl a c e d r i t h e t y mp a n i c me mb r a n e , f o l l o we d b y
a gr af t a n d t h e o bl i t e r a t i o n of t h e a di t us ( wi t h e i t h e r
pe r i o s t e um o r c a r t i l a ge ) ( Fi g. 1 0 - 1 6 ) . T h e c a vi t y ( by
no w t h e " o p e n " o r " e x t e r i o r i z e d" ma s t o i d c a vi t y ) i s
c o v e r e d by t h e f l ap. A T h i e r s c h gr af t c a n be pl a c e d
pr i ma r i l y b ut i s us ua l l y d o n e af t er s i x t o e i gh t we e k s ,
wh e n h e a l t h y gr a nul a t i o n t i s s ue i s c o v e r i ng t h e ma s -
t oi d c a vi t y ( " b o wl " ) . On o c c a s i o n, c o v e r a g e wi t h t he
fl ap a l o ne a l l o ws a de qua t e e pi t h e l i a l i za t i o n o f t h e
c a vi t y, a n d s ki n gr a f t i ng ( Th i e r s c h gr a f t ) i s no t ne c -
e s s a r y . T h e a i m i s t o o b t a i n a we l l - e pi t h e l i a l i ze d,
s af e, " e x t e r i o r i z e d" ma s t o i d c a vi t y.
Modified Radical Mastoidectomy
T h e s a me pr i nc i pl e s o b s e r v e d i n a n i nt a c t br i dge
ma s t o i d e c t o my a ppl y h e r e . I n t h i s pr o c e dur e , h o w-
e ve r , t h e b r i dge i s r e mo v e d . T wo a ppr o a c h e s a r e
po s s i b l e f or h e ma s t o i d e c t o my i n t h e mo di f i e d r ad-
i cal a ppr o a c h : ( 1) t h e " i ns i de - o ut " o r a t t i c o t o my -
a nt r o t o my , a nd ( 2) t h e " o ut s i de - i n" o r a nt r o t o my -
a t t i c o t o my ( s t a r t i ng f r om t h e ma s t o i d s i de ) . T h e l at t er
i s t h e a p p r o a c h t ha t h a s b e e n de s c r i b e d pr e v i o us l y
for ma s t o i de t o my t h a t i s , dr i l l i ng i s i ni t i a t e d f r om
t h e ma s t o i d s i de t o wa r d t h e a nt r um
Text continued on page 191
FIGURE 10 -12
FIGURE 10 -13
189
Cartilage
POAP
Surgical Procedures in Different Forms of Otitis Media
Graft
A
c
FIGURE Io-IS.
Tensor
tympani
Aditus
Pathology
Laleralize malleus
c
Surgical Procedures in Different Forms of Otitis Media
FIGURE 10-14.
188
KICURFC 10-16.
S ur gi c a l P r o c e dur e s i n Di f f e r e nt F o r ms o f Ot i t i s Me di a 191
I n s c l e r o t i c ma s t o i ds wi t h s c a r c e ai r c e l l s or c e l l s
f i l l ed wi t h di s e a s e d t i s s ue , a s a f e o ut s i de - i n pr o c e -
dur e c a n b e e x t r e me l y di f f i cul t . I n s uc h c a s e s , t h e
i ns i de - o ut a ppr o a c h i s ut i l i ze d. I n t e r ms o f o r i e nt a -
t i on, i t i s e a s i e r t o s t a r t dr i l l i ng a t t h e e p i t y mp a n u m,
mo v i n g i n t h e di r e c t i o n o f t h e a nt r um. Th i s a l l o ws
i mme di a t e i de nt i f i c a t i o n o f t h e a nt r um, t h e d o me o f
t h e s e mi c i r c ul a r c a na l , a nd t h e po s i t i o n o f t h e f aci al
ne r v e . Wi t h t h e s e l a ndma r ks un d e r di r e c t vi s i o n, t h e
ma s t o i d e c t o my i s mo r e e a s i l y pe r f o r me d, a nd t he
po s t e r i o r wa l l i s l o we r e d t o t h e l e ve l of t h e f aci al
r i dge . As me n t i o n e d e a r l i e r , t h i s a ppr o a c h i nv o l v e s
r e mo v a l o f t h e b r i dge . I n a n i nt a c t - br i dge ma s t o i de c -
t o my , h o we v e r , i t ma y be po s s i b l e t o pa l pa t e t h e
a nt r um wi t h a Wh i r l y b i r d, i de nt i f y t h e a nt r a l s pa c e ,
a nd dr il l a n o pe ni ng i mme di a t e l y s upe r i o r t o t he
b r i dge ( a s i n t h e s o - c a l l e d " o b s e r v a t i o n wi n d o ws " ) .
Th i s o p e n i n g i s c a r e f ul l y e nl a r ge d a n d a n i ns i de - o ut
pr o c e dur e i ni t i a t e d, t h us l e a v i ng t h e b r i dge i nt a c t .
T y mp a n o p l a s t y pr o c e dur e s c a n be pe r f o r me d i n a
mo di f i e d r adi cal ma s t o i de c t o my .
Radical Mastoidectomy
Th i s pr o c e dur e i s s e l do m pe r f o r me d a t pr e s e nt .
Er a di c a t i o n o f di s e a s e c a n b e a c h i e v e d b y t h e pr o c e -
dur e s de s c r i b e d a b o v e ; t h e s e i n t ur n a l l o w r e c o n-
s t r uc t i o n, t h us a v o i di ng t h e h e a r i ng l o s s i nh e r e nt i n
a r a di c a l ma s t o i de c t o my .
T h e a i m o f t h i s pr o c e dur e i s t o c r e a t e a n e xt e r i o r -
i ze d c a vi t y t ha t i nc l ude s t h e ma s t o i d, a nt r um, epi -
t y mp a n u m, a nd me s o t y mp a n u m, l e a vi ng a dr y, e p-
i t h e l i a l i ze d c a vi t y c o nt i nuo us wi t h t h e e xt e r na l
me a t us . Th i s a p p r o a c h i s s i mi l a r t o t h e mo di f i e d
r adi cal pr o c e dur e , but a l s o i nv o l v e s r e mo v a l o f t he
mu c o s a , t h e ma l l e us , a n d t h e i nc us wh i l e l e a vi ng t he
s t a pe s i nt a c t . T h e e us t a c h i a n t ub e o pe ni ng i s obl i t e r -
a t e d wi t h a b o n e pl ug.
The "Exteriorized"
Mastoid Cavity
P o s t o pe r a t i v e c a r e o f a n o p e n ( e xt e r i o r i ze d o r
" c a na l wa l l d o wn " ) c a vi t y i s o f t h e ut mo s t i mpo r -
t a nc e . No t i nf r e que nt l y , a s a t i s f a c t o r y pr o c e dur e fail s
o wi n g t o l a c k o f a de qua t e po s t o pe r a t i v e l ocal c a r e .
T h e i mpo r t a nc e o f a me a t o pl a s t y h a s a l r e a dy b e e n
s t r e s s e d. Ca r e o f t h e ma s t o i d c a vi t y i s i ni t i a t e d dur i ng
t he pr o c e dur e i t s e l f b y o b t a i ni ng a n e v e n, s mo o t h
ma s t o i d b o wl ( c a vi t y ) s ur f a c e , a de qua t e f l ap c o v e r -
a ge , a nd pa c ki ng t ha t f a vo r s e pi t h e l i a l i za t i o n. T h e
pr i ma r y o b j e c t i v e i s a we l l - e pi t h e l i a l i ze d, dr y ma s t -
oi d c a vi t y . Epi t h e l i a l i za t i o n i s a c h i e v e d by a ge ne r -
o us f l ap ( wi t h f ur t h e r e pi t h e l i a l i za t i o n) o r by s ki n
( Th i e r s c h ) gr a f t s d o n e dur i ng t h e pr i ma r y pr o c e dur e
o r s i x t o e i gh t we e k s a f t e r s ur ge r y . O n c e e pi t h e l i a l i -
za t i on i s a c h i e v e d, o p e n c a v i t i e s t e nd t o a c c umul a t e
e pi t h e l i a l de b r i s a nd c e r u me n a n d r e qui r e c l e a ns i ng
e v e r y s i x mo n t h s t o o n e y e a r . Be c a u s e a s ma l l c a vi t y
i s de s i r e d, a de qua t e s a uc e r i za t i o n i s i mpo r t a nt . If a
l a r ge c a v i t y i s t o be o b t a i ne d, ma s t o i d o bl i t e r a t i o n
( de s c r i b e d b l o w ) pr e f e r a b l y s h o ul d b e do ne .
P a c ki ng o*' t h e c a vi t y va r i e s a c c o r di ng t o t h e s ur -
g e o n' s pr e f e r e nc e a nd e x pe r t i s e . Ge l f o a m wi t h ant i -
bi ot i c o i nt me nt o r s o l ut i o n c a n be us e d; o t h e r s ur -
g e o n s pr e f e i a r o s e b ud pa c k f a s h i o ne d f r o m O we n ' s
s i l k a n d c o t t o n s a t ur a t e d wi t h a n a nt i bi o t i c - s t e r o i d
s o l ut i o n. ( Fr e e c o t t o n e n c o u r a g e s i nf e c t i o n a nd f or -
ma t i o n o f gr a nul a t i o n t i s s ue . ) Th i s pa c ki ng i s a dv a n-
t a ge o us wh e n a t y mp a n o p l a s t y i s d o n e a n d a c e r t a i n
de gr e e o f pr e s s ur e i s de s i r a b l e ; t h i s i s a l s o t r ue for
a ppo s i t i o n o f t h e s ki n f l ap t o t h e wa l l o f t h e ne wl y
f o r me d c a vi t y . T h e o ut e r o ne - t h i r d ( me a t a l a r e a )
us ua l l y i s pa c ke d wi t h g a uz e s a t ur a t e d wi t h a n
a nt i bi o t i c o i nt me nt . O we n ' s s i l k mus t be r e mo v e d a
ma x i mu m o f t wo we e k s a f t e r s ur ge r y ; o t h e r wi s e i t
a dh e r e s t o t h e wa l l s o f t h e c a vi t y a n d ne c e s s i t a t e s a
n e w pr o c e dur e t o r e mo v e i t ( s uc h a s c ur e t t i ng o r
c l e a ns i ng) . T h e pa c ki ng us e d i s no t s o c r uc i a l a s t he
r a t i o na l e f or s e l e c t i ng it.
To pi c a l a nt i bi o t i c s , s t e r o i ds , a nd pr o ph y l a c t i c a n-
t i bi ot i c s a r e us e d r o ut i ne l y , s i nc e t h e s e pr o c e dur e s
a r e pe r f o r me d i n s e v e r e l y i nf e c t e d t i s s ue s . Ext e r na l
dr e s s i ngs a r e r e mo v e d s e v e n da y s af t er s ur ge r y a nd
i nne r dr e s s i ng s a t 10 t o 14 da y s . T h o r o u g h c l e a ns i ng
o f t h e c a v i t y i s e s s e nt i a l . Re mo v a l o r c a ut e r i za t i o n
( or b o t h ) o f a ny s ma l l a r e a s o f gr a nul a t i o n t i s s ue i s
c r uc i a l . I f ne c e s s a r y , l ocal a c i di f i c a t i on wi t h s o l ut i o ns
o f bo r i c a c i d p o wd e r s h o ul d be do ne ; a t t i me s , da i l y
c l e a ns i ng i s n e e d e d . Th i s me t i c ul o us c a r e i s e s s e nt i a l
unt i l e pi t h e l i a l i za t i o n o c c ur s . I f s ki n gr a f t i ng i s
ne e de d ( s e e t h e di s c us s i o n o f Th i e r s c h gr a f t i ng i n
Ch a pt e r 7 ) , i t i s do ne s i x t o e i gh t we e k s a f t e r s ur ge r y .
S ki n c o v e r a g e pr e v e nt s i nf e c t i o n o f e x po s e d a r e a s .
Mastoid Obliteration Procedure
Wh e n t h e ma s t o i d c a vi t y i s s ma l l , a n o bl i t e r a t i o n
pr o c e dur e i s not n e e d e d . If a ma s t o i d o bl i t e r a t i o n
pr o c e dur e i s ne c e s s a r y , i t us ua l l y i s d o n e i n t h e
c o ur s e o f a t y mp a n o ma s t o i d e c t o my . Dur i ng t h e ma s -
t o i de c t o my e v e r y ef f or t s h o ul d b e ma d e t o ma k e t h e
9 2 S ur gi c a l P r o c e dur e s i n Di f f e r e nt F o r ms o f Ot i t i s Me di a
t e s t o i d c a vi t y s ma l l . Wi d e dr i l l i ng a r o un d t h e ma s -
j i d c a vi t y h e l ps t o r e duc e its s i ze .
Aim
To ma k e t h e ma s t o i d c a vi t y s ma l l e r o r t o mi ni mi z e
c r obl e ms a r i s i ng f r om a l a r ge ma s t o i d c a vi t y .
I
L 1. P o s t a ur i c ul a r a ppr o a c h .
L 2. El e v a t i o n a nd i ns e r t i o n of a mus c ul o f a s c i a l fl ap,
J 3. S pl i t - t h i c kne s s s ki n gr a f t .
I , 4. Cl o s ur e a nd pa c ki ng
i Pitfalls
I 1. I n c o mp l e t e r e mo v a l of unde r l y i ng di s e a s e
I 2- i nf e c t i o n of t h e f l ap.
3. Re s o r pt i o n a nd r e t r a c t i o n o f t h e gr af t .
F 4. S we l l i ng o f t h e f l ap, c a us i ng di s r upt i o n o f o s -
i i cl es .
Procedure
MJ e f o r e a po s t a ur i c ul a r i nc i s i o n i s ma d e , t h e t y pe
mus c ul a r f l ap t ha t wi l l be us e d t o o bl i t e r a t e t h e
na s t o i d c a vi t y s h o ul d b e de c i de d upo n. T h e f l a p c a n
D E b a s e d e i t h e r s upe r i o r l y or i nt e r i o r l y , but i n ge ne r a l
i n i nf e r i or l y pe di c l e d fl ap i s mo r e us e f ul ( Fi g. 1 0 -
17/ 1) . T h e f l ap i nc l ude s mus c l e , f a s c i a , a nd pe r i os -
t e um. Be f o r e t h e f l ap i s t ur ne d i nt o t h e ma s t o i d
: a vi t y, al l di s e a s e , e s pe c i a l l y a c h o l e s t e a t o ma i n t h e
: a vi t y, s h o ul d be r e mo v e d. T h e pe di c l e d f l ap i s
e l e va t e d f r o m t h e b o n e , r o t a t e d, a nd i ns e r t e d i nt o
t he ma s t o i d c a vi t y ; i t c a n t h e n be c o v e r e d wi t h
e pi t h e l i um pr e v i o us l y e l e v a t e d f r om t h e ma s t o i d
c a vi t y o r t h e po s t e r i o r c a na l
A P a l va ' s f l ap i s b r o a dl y b a s e d on t h e c o nc h a . A
wi de a r e a o f t h e po s t a ur i c ul a r mus c ul o pe r i o s t e um i s
i nc l ude d i n t h i s f l a p ( Fi g. 1 0 - 1 7 6 ) .
A l a r ge me a t o pl a s t y s h o ul d be d o n e a s par t of a n
o bl i t e r a t i o n pr o c e dur e . A l a r ge pi e c e of c o nc h a ] car -
t i l a ge i s r e mo v e d wi t h o ut t e a r i ng o r pe ne t r a t i ng t he
^Bthal s ki n ( Fi g. 1 0 - 1 7 C) . A Ko r ne r ' s f l ap is de ve l -
Bffd b y ma ki ng l o ngi t udi na l i nc i s i o ns at 12 a nd 6
o ' c l o c k i n t h e c a na l e x t e ndi ng o ut t o t h e a ur i c l e ( Fi g.
1 0 - 1 7 D ) . T h e me a t us s h o ul d b e l a r ge e n o u g h t o
a dmi t t h e s ur g e o n' s f o r e f i nge r . T h e Ko r ne r ' s f l ap i s
pl a c e d b e t we e n t h e mus c ul o pe r i o s t e a l f l ap a n d t h t
pa c ki ng ( Fi g. 1 0 - 1 7 E) . T h e po s t a ur i c ul a r i nc i s i o n i *
c l o s e d a nd t h e l a t e r a l c a na l i s pa c ke d wi t h '/2-ir*
ga uz e s t r i ps s a t ur a t e d wi t h a nt i bi o t i c o i nt me nt . T h e
o ut e r pa c ki ng i s r e mo v e d i n o n e we e k a n d t h e i nne r
pa c ki ng i n t wo we e k s
Surgery for Complications of
Suppurative Otitis Media
Co mpl i c a t i o ns o f s uppur a t i v e ot i t i s me di a a r e c l a s -
s i f i ed i nt o t wo ma j o r c a t e go r i e s , i nf r a t e mpo r a l a nd
e x t r a t e mpo r a l . I nt r a t e mpo r a l b o n y c o mpl i c a t i o ns in-
c l ude c o a l e s c e nt ma s t o i di t i s , f aci al ne r v e pa r a l y s i s ,
pe t r o s i t i s , a n d l a by r i nt h i t i s . Ex t r a t e mpo r a l b o ny
c o mpl i c a t i o ns a r e di v i de d i nt o i nt r a c r a ni a l a nd e xt r a -
c r a ni a l . I nt r a c r a ni a l c o mpl i c a t i o ns i nc l ude e xt r a dur a l ,
s ub dur a l a n d c e r e b e l l a r a b s c e s s e s , me n i n g i t i s ,
s i gmo i d s i nus t h r o mb o ph l e b i t i s , a nd ot i t i c h y dr o -
c e ph a l us ; e xt r a c r a ni a l c o mpl i c a t i o ns i nc l ude s u b p e r
i os t e a l , po s t a ur i c ul a r , Be z o l d' s , a nd z y g o ma t i c ab-
s c e s s e s . O wi n g t o t h e us e o f a nt i bi o t i c s , t h e s e
c o mpl i c a t i o ns a r e r e l a t i ve l y r a r e b ut stil l o c c ur . Ne w
i ma gi ng t e c h ni que s ( CT s c a n a nd MR1 ) h a v e r e vol u-
t i o ni ze d t h e t r e a t me nt o f t h e s e c o mpl i c a t i o ns , e s pe -
c i a l l y i nt r a c r a ni a l c o mpl i c a t i o ns . S ur gi c a l t r e a t me nt s
pe r t i ne nt t o o t o l o gi c s ur g e o n s a r e de s c r i b e d b e l o w.
Coalescent Mastoiditis
P a t i e nt s wi t h c o a l e s c e nt ma s t o i di t i s a r e t r e a t e d
wi t h a c o mpl e t e ma s t o i d e c t o my ( s e e Ch a pt e r s 5 a nd
7 ) . Co mmu n i c a t i o n s h o ul d b e e s t a b l i s h e d b e t we e n
t h e ma s t o i d a nd t h e mi ddl e e a r c a vi t y . T h e f aci al
r e c e s s ma y h a v e t o be o p e n e d . A l a r ge my r i ngo t o my *
a nd i ns e r t i o n o f a t y mp a n o s t o my t ub e h e l p dr a i na ge ,
af t er s ur ge r y .
Facial Nerve Paralysis
Fa c i a l ne r v e pa r a l y s i s ma y de v e l o p i n a s s o c i a t i o n
wi t h a n a c ut e s uppur a t i v e ot i t i s me di a , e s pe c i a l l y i n
y o u n g e r ( pe di a t r i c ) pa t i e nt s . A wi d e my r i n g o t o my i s
do ne a nd pus i s dr a i ne d. A l a r ge - bo r e t y mp a n o s t o my
t ube ma y be i ns e r t e d a t t h e s a me t i me t o h e l p f ur t h e r
S ur gi c a l P r o c e dur e s i n Di f f e r e nt F o r ms o f Ot i t i s Me d i a
FIGURE 10 -17.
194 S ur gi c a l P r o c e dur e s i n Di f f e r e nt F o r ms o f Ot i t i s Me di a
dr a i na ge . I nt e ns i v e pa r e nt e r a l a nt i bi o t i c s a r e gi ve n;
af t er s e ve r a l do s e s , c o r t i c o s t e r o i ds a r e a dde d. T h e
pa t i e nt i s f o l l o we d wi t h e l e c t r o di a gno s t i c t e s t s . De -
c o mp r e s s i o n o f t h e f aci al ne r v e r a r e l y i s ne c e s s a r y .
On t h e o t h e r h a nd, f aci al pa r a l y s i s o c c ur r i ng wi t h
c h r o ni c ot i t i s me di a r e qui r e s p r o mp t e x pl o r a t i o n a nd
d e c o mp r e s s i o n o f t h e ne r v e .
Petrositis
s t e ps i nc l ude a po s t a ur i c ul a r i nc i s i o n, a c o mp l e t e
ma s t o i de c t o my , e x po s ur e o f dur a , a nd dr a i na ge o f
t h e a b s c e s s . T h e b o n y pl a t e o v e r t h e dur a i s c a r e f ul l y
r e mo v e d wi t h a d i a mo n d b ur a nd c ur e t ( Fi g. 1 0 -
1 9 B) . Gr a nul a t i o n t i s s ue o v e r t h e dur a c a n b e c a r e -
ful l y pe e l e d of f or l eft a l o ne .
A s ub dur a l or br a i n a b s c e s s i s ma n a g e d i n c o o p -
e r a t i o n wi t h ne ur o s ur gi c a l c o l l e a gue s . I t c a n be
dr a i ne d t o t h e ma s t o i d c a vi t y .
Pe t r os i t i s ma ni f e s t s i t s e l f c l i ni c a l l y wi t h de e p pa i n,
pa l s y o f c r a ni a l ne r v e VI , a n d o t o r r h e a ( Gr a de ni g o ' s
s y n d r o me ) . Pa i n ma y b e t h e o nl y c o mpl a i nt . On c e
t h e di a gno s i s i s ma d e , t h e pa t i e nt wi t h pe t r o s i t i s i s
t r e a t e d wi t h i nt e ns i v e a nt i mi c r o b i a l t h e r a py a nd s ur -
ge r y . A c o mp l e t e e x t e nde d ma s t o i d e c t o my i s do ne ,
wi t h s pe c i a l e mp h a s i s o n l o c a t i o n a nd e x e nt e r a t i o n
o f t h e cel l t r a c ks a r o und t h e s e mi c i r c ul a r c a na l s ; i f
t h i s i s uns uc c e s s f ul , a n a p i c e c t o my mi gh t be ne c e s -
s a r y . S ur gi c a l a ppr o a c h e s t o t h e pe t r o us a pe x ma y
be ma d e t h r o ugh t h e s ub a r c ua t e ai r cel l t r act ; t he
[ s i no dur a l a ngl e ; t h e t r act b e ne a t h t h e po s t e r i o r c a na l
a nd ve r t i c a l po r t i o n o f t h e f aci al ne r ve ; t h e h y po t y m-
s pa ni c c e l l s ; t h e pe r i t uba l c e l l s t o t h e pe t r o us a pe x
[ b e t we e n t h e c o c h l e a a nd t h e c a r o t i d a r t e r y; a nd t he
mi ddl e f os s a ( Fi g. 1 0 - 1 8 ) .
Labyrinthitis
; P a t i e nt s wi t h l a by r i nt h i t i s pr e s e nt wi t h s e ns o r i -
ne ur a l h e a r i ng l os s , t i nni t us , a nd ve r t i go . Initial
t r e a t me nt i nc l ude s h o s pi t a l i za t i o n, h y dr a t i o n, ant i -
mi c r o bi a l t h e r a py , a nt i v e r t i gi no us me di c a t i o ns , a nd
a my r i n g o t o my ; i f t h e r e i s no i mp r o v e me n t , s ur gi c a l
i nt e r v e nt i o n s h o ul d be c o ns i de r e d. A c o mp l e t e ma s -
t o i de c t o my i s do ne . T h e l a by r i nt h c a n be dr a i ne d
wi t h a l a b y r i nt h e c t o mv a ppr o a c h . In t h i s pr o c e dur e ,
t h e po s t e r i o r a nd h o r i zo nt a l s e mi c i r c ul a r c a na l s a r c
o p e n e d . T h e b o n y wal l b e t we e n t he o va l a nd r o und
wi n d o ws i s r e mo v e d , a l o ng wi t h t he l at er al e nd o f
t h e i nt e r na l a udi t o r y c a na l . I n a ddi t i o n, t h e s i gmo i d
s i nus a nd dur a o f t h e mi ddl e a nd po s t e r i o r c r a ni a ]
f os s a a r e e x p o s e d t o i de nt i f y a nd dr a i n a ny pus i n
t h e s e a r e a s .
Intracranial Abscess
I nt r a c r a ni a l a b s c e s s e s ma y o c c ur a t a n e xt r a dur a l
or a s ub dur a l s i t e , or i n t h e b r a i n i t s e l f ( Fi g. 1 0- 1 9 / 1 ) .
I
An e xt r a dur a l l o c a t i o n i s t h e mo s t c o mmo n .
T h e e xt r a dur a l ( e pi dur a l o r s ub pe r i o s t e a l ) a b s c e s s
ma y be a t t h e mi ddl e o r po s t e r i o r f o s s a . Sur gi c a l
Meningitis
Me ni ngi t i s i s t h e mo s t c o mmo n i nt r a c r a ni a l c o m-
pl i c a t i o n. T h e pr i ma r y mo d e o f t r e a t me nt i s i nt e ns i v e
a nt i mi c r o bi a l t h e r a py ; wh e n s ur gi c a l i nt e r v e nt i o n i s
i ndi c a t e d, t h e pr o c e dur e i s e s s e nt i a l l y t h e s a me ar;
t hat f or a n e x t r a dur a l a b s c e s s
Sigmoid Sinus Thrombophlebitis
S uppur a t i v e ot i t i s me di a c a n c a us e i nf l a mma t i o n
a r o und t h e s i g mo i d s i nus , r e s ul t i ng i n a l o c a l i ze d
ph l e bi t i s . P h l e bi t i s pr o mo t e s f o r ma t i o n of a mur a l
t h r o mb us , wh i c h ma y e nl a r ge , o c c l ude t h e l ume n,
a nd b e c o me i nf e c t e d. S y mp t o ms o f s i gmo i d s i nu:
t h r o mb o ph l e b i t i s i nc l ude s pi ki ng f e ve r , c h i l l s , h e a d
a c h e , i nc r e a s e d i nt r a c r a ni a l pr e s s ur e , a nd pos t
a ur i c ul a r e d e ma ( Gr i e s i nge r ' s s i gn)
T h e t r e a t me nt i s a ppr o pr i a t e a nt i mi c r o bi a l t h c r a p\
a nd s ur ge r y S ur gi c a l s t e ps i nc l ude a c o mpl e t e ma s
t o i de c t o mv , e x p o s u r e o f t h e s i gmo i d s i nus , nc c dU
a s pi r a t i o n o f t he s i nus , e v a c ua t i o n o f t he t h r o mb us ,
l i ga t i on o f t h e i nt e r na l j ugul a r ve i n, a nd pa c ki ng a nd
c l o s ur e
At tor a c o mp l e t e ma s t o i d s l o mv i s do ne , t h e b o m
pl a t e o v c r l v i ng t h e s i gmo i d s i nus i s t h i nne d wi l l ,
di a mo nd bur s a nd r e mo v e d pr o x i ma l l v a nd di s t al l v
wi t h a c ur e t or e l e v a t o r unt i l no r ma ] s i nus a ppe a r s .
Af t e r t h e s i gmo i d s i nus i s e x p o s e d , a ne e dl e ( wi t h
s y r i nge ) i s i ns e r t e d i nt o t h e s i nus di s t a l l y. I f b l o o d i s
a s pi r a t e d f r e e l y, no f ur t h e r pr o c e dur e i s ne c e s s a r y
a nd t h e wo u n d i s c l o s e d. I f t h e r e i s e v i de nc e of a
c l ot , t h e s i nus i s o p e n e d a nd t h e t h r o mb u s i s r e-
mo v e d unt i l b l o o d f l o ws f r eel y ( Fi g. 1 0 - 1 9 C, D) .
P a c ki ng i mpr e g na t e d wi t h a nt i bi o t i c s i s i ns e r t e d be-
t we e n t he wal l o f t h e s i nus a nd t h e o v e r l y i ng b o ny
pl a t e .
I f t h e r e i s no r e t r o gr a de b l e e di ng a nd t h r o mb u s i s
s us pe c t e d a t t h e b ul b o r i nf e r i or l o c a t i o n, t h e i nt e r na l
j ugul a r ve i n i s l i ga t e d i n t h e ne c k; t h e i nc i s i o n i s
ma d e a l o ng t h e a nt e r i o r b o r de r o f t h e s t e r no c l e i do -
ma s t o i d mus c l e ( Fi g. 1 0- 2 0/ 1 ) . T h e mus c l e i s r e t r a c t e d
S ur gi c a l P r o c e dur e s i n "Hf f er ent F o r ms o f Ot i t i s Me d i a 195
S ur gi c a l P r o c e dur e s i n Di f f e r e nt F o r ms o f Ot i t i s Me di ,
Dura
FIGURE 10 -19
S ur gi c a l P r o c e dur e s i n Di f f e r e nt F o r ms o f Ot i t i s Me di
FIGURE 10 -20
198 S ur gi c a l P r o c e dur e s i n Di f f e r e nt F o r ms o f Ot i t i s Me di a
po s t e r i o r l y , a nd t h e i nt e r na l j ugul a r ve i n i s i de nt i f i e d
a nd do ub l y l i ga t e d ( Fi g. 1 0 - 2 0 8 ) . T h e v a g us ne r v e
s h o ul d be po s i t i ve l y i de nt i f i e d be f o r e t h e ve i n i s
l i ga t e d.
T h e wo u n d i s pa r t i a l l y c l o s e d. P a c ki ng s o n t he
s i nus a r e r e mo v e d i n 7 t o 10 da y s ; t h i s s h o ul d be
do ne i n t h e o pe r a t i ng r o o m o wi n g t o t h e pos s i bi l i t y
o f b l e e di ng.
Periauricular Abscesses
l i on of a t y mp a n o s t o my t ub e wi t h or wi t h o u a
s i mpl e ma s t o i d e c t o my
F r e que nt l y t h e ma s t o i d r e t ur ns t o no r ma l by h e
t i me t h e a b s c e s s i s dr a i ne d. Ho we v e r , a ma s t o i d !C-
t o my i s h e l pf ul i n r e mo v i n g a ny r e ma i ni ng f o c us o f
i nf e c t i o n o r unde r l y i ng pa t h o l o gy . An y b l o c ka g e a t
t h e a di t us a d a n t r um i s r e mo v e d . A my r i n g o t o n y
a nd i ns e r t i o n of a t y mp a n o s t o my t ub e h e l p f ur t l e r
dr a i na ge . A P e n r o s e dr a i n ma y be i ns e r t e d i nt o t i e
a b s c e s s c a vi t y dur i ng s ur ge r y ; i t i s a dv a nc e d g r a c
1
i -
al l y a nd r e mo v e d i n t wo t o t h r e e da y s .
I nf e c t i on o f t h e mi ddl e e a r a nd ma s t o i d c a n c a us e
a b s c e s s f o r ma t i o n a r o und t h e a ur i c l e . An a b s c e s s
ma y de v e l o p po s t e r i o r l y ( po s t a ur i c ul a r ) , a nt e r i o r l y
( z y go ma t i c ) , o r i nt e r i o r l y ( Be z o l d' s ) ( Fi g. 1 0 - 2 0 C)
T h e po s t a ur i c ul a r a b s c e s s i s t h e mo s t c o mmo n .
Tr e a t me nt i nc l ude s a nt i mi c r o b i a l t h e r a py a nd s ur -
ge r y . S ur gi c a l t r e a t me nt c o ns i s t s o f i nc i s i o n a nd
dr a i na ge o f t h e a b s c e s s , a my r i n g o t o my , a nd i ns e r -
Pertinent Histopathology
F I G UR E 1 0- 2 1
Th i s s e c t i o n s h o ws a n e pi s o de o f a c ut e ot i t i s me d a
wi t h pe r f o r a t i o n o f t h e t y mpa ni c me mb r a n e . No . e
t ha t t h e mu c o p e r i o s t e u m o v e r l y i ng t h e p r o mo n t o y
i s t h i c ke ne d.
S ur gi c a l P r o c e dur e s i n Di f f e r e nt F o r ms o f Ot i t i s Me d i a 199
F I G UR E 1 0 - 2 2
T h i s s e c t i o n s h o ws a mi d d l e e a r e f f us i o n o c c u - i s t h i c k e n e d . T h i s i s a t y pi c a l i ma g e o f mu c o i d o t i -
p y i n g t h e mi d d l e e a r c a v i t y . T h e mu c o p e r i o s t e u m tis.
2 02 S ur gi c a l P r o c e dur e s i n Di f f e r e nt F o r ms o f Ot i t i s Me di a
F I G UR E 1 0 - 2 5
Th i s s e c t i o n s h o ws a ma r ke dl y r e t r a c t e d, a t r o ph i c o b v i o us l y a di f f i cul t t a s k t o pe r f o r m pr o pe r l y T h e
. t y mpa ni c me mb r a n e wi t h a s o - c a l l e d "r e t r a c t i o n t h i nne s s o f t h e me mb r a n e j us t i f i e s r e i nf o r c e me nt
po c ke t . No t e t h e s ma l l mi ddl e e a r s pa c e a va i l a bl e , wi t h f as ci a dur i ng s ur gi c a l r e pa i r ( e v e n i f t h e me t i -
El e v a t i o n o f t hi s me mb r a n e wi t h o ut a n y t e a r s i s b r a ne i s e l e v a t e d i nt a c t ) .
S ur gi c a l P r o c e dur e s i n Di f f e r e nt F o r ms o f Ot i t i s Me d i a 2 03
F I G UR E 1 0 - 2 6
T h i s s e c t i o n s h o ws a n a t e l e c t a t i c t y mp a n i c me m-
b r a ne a ga i ns t t h e pr o mo nt o r y . At e l e c t a t i c o r r e t r a c t e d
me mb r a n e s t e nd t o h a v e s ma l l a mo u n t s o f mi ddl e
e a r e f f us i o ns . T h e " a d h e s i v e n e s s " o f t h e t y mpa ni c
me mb r a n e a nd t h e c o mmo n f o r ma t i o n o f a dh e s i o ns
i n ot i t i s me di a pr o c e s s e s j us t i f y t h e us e o f t hi n Si l a s t i c
s h e e t s , wh i c h t e nd t o pr e c l ude t h e s e f o r ma t i o ns ,
t h us ma i nt a i ni ng a mi ddl e e a r s pa c e a nd t h e f r e e
mo bi l i t y o f t h e t y mpa ni c me mb r a n e a nd o s s i c l e s .
S e c t i o ni ng o f t h e t e ns o r t y mpa ni ( wh e n t h e r e i s
f i br o us i nv o l v e me nt ) a l s o a l l o ws a l a r ge r mi ddl e e a r
s pa c e a nd b e t t e r t y mpa ni c me mb r a n e mo bi l i t y ( no t
s h o wn i n t h i s f i gur e ) .
!0 4 S ur gi c a l P r o c e dur e s i n Di f f e r e nt F o r ms o f Ot i t i s Me d i a
F I G UR E 1 0 - 2 7
Be ne a t h t he s ma l l "r e t r a c t i o n p o c k e t " l i es a mi ddl e-
e a r c a vi t y fil l ed wi t h c o nne c t i v e t i s s ue a nd a di s e a s e d
ma s t o i d c o nt a i ni ng a c h o l e s t e r o l g r a nul o ma ( CO) a nd
o t h e r c h a n g e s . Thi s r e qui r e s e r a di c a t i o n o f di s e a s e
f r om bo t h i h e mi ddl e c a r a n d ma s t o i d. T h e gr a dua l
s y s t e ma t i c a ppr o a c h de s c r i b e d i n t hi s c h a pt e r a l l o ws
t he s ur ge o n t o de a l wi t h t hi s c a s e pr o pc r l v. S i mpl e
i ns e r t i o n ol a t ub e or e x pl o r a t i o n ol t h e mi ddl e c a r
not o nl y wo ul d no ! s uf f i c e but wo ul d l e a ve di s e a s e d
muc o pe r i o s t e um wi t h al l of its pot e nt i a l c o mpl i c a -
S ur gi c a l P r o c e dur e s i n Di f f e r e nt F o r ms o f Ot i t i s Me d i a 20 5
F I G UR E 1 0- 2 8
Th i s s e c t i o n s h o ws a n o t h e r c a s e o f ot i t i s me di a
c h r o ni c mi ddl e e a r i nv o l v e me nt t ha t r e qui r e s r e-
mo v a l . Ne w b o n e f o r ma t i o n i n t h e c a vi t y ma k e s t he
s ur gi c a l t a s k di f f i cul t , r e qui r i ng t h e ut mo s t c a r e .
I nc o mpl e t e r e mo v a l o f di s e a s e d t i s s ue wi l l l e a ve
di s e a s e b e h i nd; t oo a ggr e s s i v e a n a ppr o a c h c a n e x-
po s e a nd c o mp r o mi s e t h e f aci al ne r v e , wh i c h h a s a
v e r y t h i n, b o n y c o v e r i ng l a t e r a l l y a n d i s de h i s c e nt
t o wa r d t h e o va l wi n d o w. T h e s t a pe s f o o t pl a t e i s
f i xed by f i br o us t i s s ue . R e mo v i n g t h i s s t a pe s a nd
r e pl a c i ng i t wi t h a pr o s t h e s i s wo ul d t ur n t h i s c a s e
i nt o a s ur gi c a l t r a ge dy b e c a us e of t h e mi ddl e e a r
pr o c e s s i nv o l v i ng t he v e s t i b ul e . I n c h r o ni c ot i t i s , t h e
s t a pe s f o o t pl a t e a nd t h e ma l l e us t e nd t o b e c o me
f i xed b y f i br o us t i s s ue . T h e l o ng pr o c e s s o f t h e i nc us
a nd s t a pe s h e a d a n d c r ur a unde r g o r e s o r pt i o n, r e-
s ul t i ng i n o s s i c ul a r di s c o nt i nui t y .
20 6 S ur gi c a l P r o c e dur e s i n Di f f e r e nt F o r ms of
Ot i t i s Me di a
F I G UR E 1 0- 2 9
Th i s s e c t i o n s h o ws a mi ddl e e a r c a vi t y c o nt a i ni ng di s s e c t i o n o f t h e c h o l e s t e a t o ma i s i mpo r t a nt s i nc e
no t o nl y t h i c ke ne d mu c o p e r i o s t e u m but a l s o a c h o - f aci al pa r a l y s i s i s a l i ke l y c o mpl i c a t i o n of s uc h a
l e s t e a t o ma e r o di ng i nt o t h e facial ne r v e . Th i s l e s i o n, pr o c e dur e ,
i f unt r e a t e d, wi l l l e a d t o f aci al pa r a l y s i s . Ca r e f ul
S ur gi c a l P r o c e dur e s i n Di f f e r e nt F o r ms o f Ot i t i s Me d i a 20 7
F I G UR E 1 0 - 3 0
Th i s s e c t i o n s h o ws a t h i c ke ne d, r e t r a c t e d t y m- ma s t o i d a nd a nt r um a r e no t e x pl o r e d, di s e a s e wil l
pa ni c me mb r a n e wi t h a dh e s i o ns ( A) ( s po nt a ne o us b e i na dv e r t e nt l y l eft b e h i nd a nd t h e pr o c e dur e wil l
t y pe 111 t y mpa no pl a s t y ) , a t h i c k mi ddl e e a r mu c o - be i na de qua t e . Th i s c a s e s h o ul d be a ppr o a c h e d s y s -
pe r i o s t e um (parallel arrows), a nd i nv o l v e me nt of t h e t e ma t i c a l l y a s de s c r i b e d i n t h e t ext ,
ma s t o i d wi t h a c h r o ni c i nf l a mma t o r y pr o c e s s . I f t h e
2 08 S ur gi c a l P r o c e dur e s i n Di f f e r e nt F o r ms o f Ot i t i s Me di a
FIGURE 10 -31
I F I G UR E S 1 0 - 3 1 , 1 0 - 3 2
I T h e s e t wo s e c t i o ns a r e f r o m a n i ndi vi dua l wh o t er ol g r a nul o ma a nd gr a nul a t i o n t i s s ue e r o de d t h e
h a d c h r o n i c o t i t i s me di a b e h i n d a n i nt a c t t y mpa ni c b o ne , a nd t h e ma s s s h o wn i n F i gur e 1 0 - 3 2 wa s f o und
me mb r a n e , wi t h a l a r ge c h o l e s t e r o l g r a nul o ma a nd i n t h e mi ddl e c r a ni a l f o s s a . T h i s wa s no t t h e caus<:
f cf l ammat or y t i s s ue (parallel arrows) o c c upy i ng t h e of de a t h ,
ma s t o i d a n d a n t r um. ME = mi ddl e e a r . T h e c h o l e s -
S ur gi c a l P r o c e dur e s i n Di f f e r e nt F o r ms o f Ot i t i s Me d i a
FIGURE 10 -32.
CHAPTER 11
Exploratory
Tympanotomy
T h e e x pl o r a t o r y t y mp a n o t o my ( e x pl o r a t i o n o f t he
mi ddl e e a r c a v i t y ) i s h i gh l i gh t e d i n t hi s c h a pt e r a s
a n e x t r e me l y h e l pf ul a nd i n n o c u o u s di a gno s t i c a nd,
o f t e n, t h e r a pe ut i c pr o c e dur e . As a n i nt e gr a l pa r t o f
a t y mpa no pl a s t y , i t i s t h e r a pe ut i c ; us e d i n t h e pr e s -
e nc e o f a n i nt a c t t y mpa ni c me mb r a n e wh e n a di a g-
no s i s of e a r di s e a s e i s i n do ub t , i t i s di a gno s t i c . Th i s
e x pl o r a t i o n c a n be pe r f o r me d a s a t r a ns c a na l pr o c e -
dur e ( wh e n s us pe c t e d di s e a s e i s l i mi t e d t o t h e mi ddl e
e a r ) o r a s a n e nda ur a l pr o c e dur e ( wh e n s us pe c t e d
Hi s e a s e i nv o l v e s t h e at t i c o r ma s t o i d, o r b o t h ) . T h e
y mp a n o t o my c a n b e d o n e unde r l ocal o r ge ne r a l
i
a ne s t h e s i a ( de pe ndi ng o n t he c a s e ) , a nd c a n b e us e d
unde r ma n y di f f e r e nt cl i ni cal c i r c ums t a nc e s , s uc h a s
i n c a s e s o f une x pl a i ne d c o nduc t i v e h e a r i ng l o s s a nd
o c c a s i o na l s e ns o r i ne ur a l h e a r i ng l o s s e s ( f or e x a mp l e ,
i f t h e r e i s s us pi c i o n of pe r i l y mph a t i c f i s t ul a e ) , or
wh e n t h e pr e s e nc e o f a dh e s i o ns o r a l o c ul a t e d mi ddl e
e a r e f f us i o n i s s us pe c t e d. Th i s c h a pt e r di s c us s e s t he
f c s e o f t he e x pl o r a t o r y t y mp a n o t o my f or po s s i b l e
pe r i l y mph a t i c f i s t ul a e a nd f or t y mpa ni c ne ur e c t o my ,
Hh e s e t o pi c s do not fit i nt o o t h e r c h a pt e r s . T h e
e s s e nt i a l c o nc e pt i s t ha t e x pl o r a t o r y t y mp a n o t o my ,
wh i c h c a n be us e d r o ut i ne l y a s a s a f e a nd s i mpl e
di a gno s t i c pr o c e dur e f or a va r i e t y of mi ddl e e a r
c o ndi t i o ns , i s a l s o po t e nt i a l l y t h e r a pe ut i c
ni t us , a nd a po s i t i ve f i s t ul a t es t , mo r e of t e n t h a n no t
t he s y mp t o ms a r e i s o l a t e d a nd r e qui r e a h i gh de g r e e
o f s us pi c i o n o n t h e pa r t o f t h e s ur g e o n.
Fi s t ul a e c a n i nv o l v e t h e r o und wi n d o w o r ova l
wi n d o w, o r b o t h , a nd a t t i me s e v e n t h e l a t e r a l
s e mi c i r c ul a r c a na l . T h e y c a n b e c a us e d b y i mpl o s i v e
o r e x pl o s i v e f or c e s ; t h us t h e y a r e no t e nt i t i e s by
t h e ms e l v e s but ma ni f e s t a t i o ns o f a n unde r l y i ng o r
c a us a t i v e pr o b l e m. Fi s t ul a e c a us e d b y gr a nul a t i o n
t i s s ue , c h o l e s t e a t o ma , a nd o t h e r f a c t or s c o ns t i t ut e
di f f e r e nt c l i ni c a l e nt i t i e s f r o m t h o s e di s c us s e d h e r e ;
t h e y a r e de s c r i b e d i n di f f e r e nt c h a pt e r s a nd c a n
i nv o l v e s t r uc t ur e s o t h e r t h a n t h e o va l a nd r o und
wi n d o ws .
R o u n d wi n d o w f i s t ul a e do not ne c e s s a r i l y i mpl y
a f l o w of pe r i l y mph a s a n e s s e nt i a l e l e me n t f or t h e
di a gno s i s . S i nc e t h e a ppr o x i ma t e a v e r a g e v o l ume s o f
pe r i l y mph a nd e n d o l y mp h a r e 7 8 . 3 a nd 2 . 7 6 c u mm
r e s pe c t i v e l y , "a f r ee f l ow of pe r i l y mph f r om t he
r o und wi n d o w" o r "a f r ee f l ow o f e n d o l y mp h af t er
o pe ni ng t h e e n d o l y mp h a t i c s a c " c a n o nl y b e a c -
c o unt e d f or b y o t h e r e x pl a na t i o ns . F r e e "f l ui d" gus h -
i ng f r o m t h e r o und wi n d o w i s no t pe r i l y mph but
c e r e b r o s pi na l fl uid a nd r e qui r e s a pa t e nt c o c h l e a r
a que duc t a nd mo di o l us . At t h e s a me t i me , wh e n t h i s
a na t o mi c pa t h wa y i s no t pr e s e nt t h e r e i s no "f r e e
f l o w, " a l t h o ugh a f i s t ul a stil l e xi s t s
Exploratory Tympanotomy for
Perilymphatic Fistula
P e r i l y mph a t i c f i s t ul ae h a v e no c o ns i s t e nt pa t h o g-
no mo ni c s i gns . Al t h o ug h s o me pa t i e nt s ma y h a v e
de a r l y s ugge s t i v e s y mp t o ms , s uc h a s h e a r i ng fl uc-
t ua t i ons a s s o c i a t e d wi t h v e s t i b ul a r di s t ur b a nc e s , tin-
Procedure
Loc a l o r ge ne r a l a ne s t h e s i a c a n be us e d. Ex pl o r a -
t or y t y mp a n o t o my f l a ps a nd e nt r a nc e i nt o t he mi ddl e
ear b e ne a t h t he a n n ul us h a v e b e e n de s c r i b e d i n
pr e v i o us c h a pt e r s . T h e po s t e r i o r c a na l i s l o we r e d
1
wi t h c ur e t t e s i n o r de r t o c l e a r l y vi s ua l i ze t h e r o und
a nd o va l wi n d o ws . ( If i nv o l v e me nt o f t h e l at er al
s e mi c i r c ul a r c a na l i s s us pe c t e d, a n e nda ur a l a ppr o a c h
i s pr e f e r r e d. )
T h e mi ddl e e a r c a v i t y , i nc l udi ng b o t h wi n d o ws ,
i s c o mpl e t e l y i ns pe c t e d. I t s h o ul d be no t e d wh e t h e r
t he r o un d wi n d o w me mb r a n e i s vi s i bl e or i n a
c o v e r e d po s i t i o n i n t h e ni c h e . I t i s a l s o i mpo r t a nt t o
di s t i ngui s h t h e me mb r a n e i t s e l f f r o m muc o s a l f ol ds
i n t h e ni c h e ( t h e s o - c a l l e d "f a l s e me mb r a n e " ) .
A f i s t ul a ma y be o b v i o us a t t h i s po i nt ( Fi g. 1 1 -
\A). I f no t , t h e o s s i c ul a r c h a i n i s mo b i l i z e d a n d ge nt l y
Ex pl o r a t o r y T y mp a n o t o my 2 11
FIGURE 11-1
pa l pa t e d a nd t h e wi n d o ws a r e o b s e r v e d f or l e a ks .
T h e p r e s e n c e o r a b s e nc e o f a r o und wi n d o w r ef l ex
( wh e n mo b i l i z i ng t h e o s s i c ul a r c h a i n) i s t o be no t e d;
i f t h e wi n d o w i s no t vi s i bl e , a f e w dr o ps of s a l i ne
s o l ut i o n c a n be pl a c e d i n t h e ni c h e i n o r de r t o o b s e r v e
s uc h a r e f l e x.
I n t h e pr e s e nc e of o b v i o us l e a ks or i f t h e r ef l ex i s
a b s e nt , a pa t c h of c o nne c t i v e t i s s ue ( c o l l a ge n) i s
pl a c e d o v e r t h e wi n d o w a nd r e i nf o r c e d wi t h Ge l f o a m
( Fi g. 1 1 - 1 B ) . ( Th e r o und wi n d o w me mb r a n e i s t h r e e -
l a y e r e d, wi t h a c e nt r a l l a y e r of c o nne c t i v e t i s s ue . ) I n
unc l e a r c a s e s , s ma l l pi e c e s o f Ge l f o a m a r e us e d t o
FI GURI ; I I - 2 .
Ex pl o r a t o r y T y mp a n o t o my 2 13
c o v e r s uc h a r e a s s i nc e s ma l l f i s t ul a e ma y no t b e
vi s ua l l y e v i de nt . ( If t h e pr o c e dur e i s b e i ng do ne
unde r l oc a l a ne s t h e s i a t h e pa t i e nt c a n b e a s ke d t o
pe r f o r m Va l s a l v a ' s ma n e u v e r . )
T h e f l a ps a r e r e po s i t i o ne d, t h e e a r c a na l i s pa c ke d,
a nd a dr e s s i ng i s a ppl i e d.
Tympanic Neurectomy
A t y mpa ni c n e u r e c t o my i mpl i e s t r a ns e c t i o n of t h e
t y mpa ni c pl e x us wi t h o r wi t h o ut di vi s i o n o f t h e
c h o r da t y mpa ni . I t i s us e d ma i nl y f or c a s e s o f dr o o l -
i ng a nd c h r o ni c pa r ot i t i s . S o me s u r g e o n s h a v e us e d
t hi s pr o c e dur e t o t r e a t c e r t a i n f o r ms o f a ur a l pa i n
a nd e v e n t i nni t us . T h e r a t i o na l e f or its pr i ma r y us e s
i s f o unde d o n t h e pa r a s y mpa t h e t i c i nne r v a t i o n o f
t h e s ub l i ngua l a n d s ub ma ndi b ul a r gl a nds ( vi a t h e
c h o r da t y mpa ni ) a nd o f t h e pa r o t i d gl a nd ( vi a t h e
t y mpa ni c pl e x us ) . Ot h e r i ndi c a t i o ns a r e b a s e d o n t h e
mul t i pl e s i t e s o f i nt e r c o nne c t i o n o f t h e s e ne r v e e nd-
i ngs wi t h o t h e r n e r v e s i n t h i s s ma l l a n a t o mi c a r e a
( wh i c h i s no t c l e a r l y de f i ne d) ( Fi g. 1 1 - 2 ) .
Procedure
Ex pl o r a t o r y t y mp a n o t o my f l aps a n d e nt r a nc e o f
t h e mi ddl e e a r b e ne a t h t h e a nnul us h a v e a l r e a dy
b e e n de s c r i b e d. I ni t i a l l y, t h e c h o r da t y mpa ni i s i s o-
l a t e d a n d a pi e c e s h a r pl y r e mo v e d . T h i s i s f o l l o we d
by a c a r e f ul s e a r c h of t h e b r a nc h e s of t h e t y mpa ni c
pl e x us t r a ve r s i ng i nt e r i or l y t o s upe r i o r l y f r om t h e
h y p o t y mp a n u m vi a t h e p r o mo n t o r y p r o mi n e n c e
( Fi g. 1 1 - 3 A) . Fo r e a s i e r vi s ua l i za t i o n, Ge l f o a m pl e dg-
et s s a t ur a t e d wi t h e pi ne ph r i ne s o l ut i o n c a n b e a p-
pl i e d t o t h e h y p o t y mp a n u m a nd p r o mo n t o r y ( bl o o d
v e s s e l s ma y o b s c ur e vi s ua l i za t i o n o f t h e s e t h i n fi-
b e r s ) . Pieces of t h e ne r v e s (at l e a s t 3 mm i n l e ngt h )
s h o ul d be r e mo v e d ( Fi g. 1 1 - 3 B) . I t i s i mpo r t a nt t o
r e me mb e r t h a t s o me ne r v e s t r a ve r s e t h e p r o mo n t o r y
t h r o ugh b o ny g r o o v e s a nd n e e d t o b e c ur e t t e d c a r e -
ful l y. Dr i l l i ng s h o ul d b e a v o i de d. On o c c a s i o n, a c -
c o mp a n y i n g v e s s e l s c a n b e r e l a t i ve l y l a r ge ( f or t h e
a r e a ) ; mi no r l o c a l i ze d b l e e di ng mi gh t r e qui r e a ppl i -
c a t i o n o f Ge l f o a m s a t ur a t e d i n e pi ne ph r i ne s o l ut i o n.
I t i s a l s o i mpo r t a nt t o v i s ua l i ze t h e h y p o t y mp a n u m;
i n a b o ut 5 0 % o f c a s e s a l a r ge r h y p o t y mp a n i c b r a nc h
i s pr e s e nt ( Fi g. 1 1 - 3 C) . T h i s b r a nc h , wh i c h s o me -
t i me s h a s a n a nt e r i o r di r e c t i o n, s h o ul d b e l o c a t e d.
Th e a r e a i s pa c ke d wi t h s ma l l pi e c e s o f c o m-
pr e s s e d Ge l f o a m, t h e f l ap i s r e po s i t i o ne d, a nd t h e
e a r i s pa c ke d.
Re s ul t s a r e c o ns i s t e nt l y s a t i s f a c t o r y i n t h e s h o r t
t e r m, but a f t e r a y e a r r e i nne r v a t i o n s e e ms t o o c c ur
i n a t least 3 0 % of c a s e s ( us ua l l y mo r e ) . T h e e x pl a na -
t i on f or t h i s , a s we l l a s f or t h e r e c o v e r y of t a s t e af t er
s e c t i o ni ng of t h e c h o r da t y mpa ni , i s unc l e a r . A
di s c us s i o n o f t h i s p h e n o me n o n i s o ut s i de t h e s c o pe
o f t h i s b o o k.
Pertinent Histopathology
F I G UR ES 1 1 - 4 T O 1 1 - 6
T h e s e t h r e e p h o t o mi c r o g r a p h s o f h o r i zo nt a l s e c -
t i o ns o f t e mpo r a l b o n e s s h o w t h e ne r v e s o f t h e
t y mpa ni c pl e x us ( TP ) , a c c o mp a n i e d b y t h e i r c o r r e -
s p o n d i n g b k o d v e s s e l s ( B V ) i n b o n y c a na l s wi t h i n
t h e p r o mo n t o r y . T h e s e a r e i mpo r t a nt a n a t o mi c f ac-
t or s t o be c o ns i de r e d f or a pr o pe r n e ur e c t o my . Ad-
di t i o na l l y , F i gur e s 1 1 - 5 a n d 1 1 - 6 s h o w a t h i c ke ne d
mu c o p e r i o s t e u m o v e r l y i ng t h e pr o mo nt o r y , ma k i n g
i de nt i f i c a t i o n o f t h e s e g r o o v e s v e r y di f f i cul t . T h e
s ur g e o n mu s t " p e e l " t h i s mu c o p e r i o s t e u m.
FIGURE 11-3
Ex pl o r a t o r y T y mp a n o t o my 2 17
FIGURE 11-6 .
CHAPTER 12
Tympanoplasty
Overview
T h e a i m of a t y mp a n o p l a s t y i s s ur gi c a l r e c o ns t r uc -
t i on o f t h e d a ma g e d t y mpa no - o s s i c ul a r c h a i n. T h e
b a s i c pr i nc i pl e s i nv o l v e d a r e e r a di c a t i o n o f di s e a s e ,
r e c o ns t r uc t i o n o f t h e t y mpa ni c me mb r a n e a nd t h e
s o u n d t r a ns f o r me r me c h a n i s m, a nd r e - e s t a b l i s h me nl
o f a n a e r a t e d c a vi t y. I de a l l y , t h e o pe r a t i o ns di s c us s e d
i n t h i s c h a pt e r a r e pe r f o r me d s o l e l y t o r e s t o r e f unc-
t i on, wi t h t h e o r i gi na t i ng o r unde r l y i ng di s e a s e wel l
unde r c o nt r o l . T h e y a r e a l s o pe r f o r me d wh e n t h e r e
a r e s e ve r a l i ndi c a t i o ns ( f or e x a mp l e , a t y mp a n o ma s -
t o i de c t o my ) .
T h e s e pr o c e dur e s i nv o l v e t h e f o l l o wi ng s t e ps :
1 . T h o r o u g h e v a l ua t i o n o f t h e s t a t us o f t h e pa t i e nt
a nd t h e a f f e c t e d e a r a s a wh o l e .
2. A s ur gi c a l a ppr o a c h b a s e d on t h e pa t i e nt ' s
ne e ds .
3. Co mp l e t e vi s ua l i za t i o n a nd e x pl o r a t i o n o f t he
e a r .
4 . As s e s s me n t
5. Re c o ns t r uc t i o n ( o nl y af t er s t e ps 1 t h r o ugh 4 a r e
d o n e ) .
6 . Cl o s u r e a n d me t h o di c a l po s t o pe r a t i v e f ol l ow-
up.
I n o r de r t o s uc c e e d, t y mpa no pl a s t y mus t be a p-
pr o a c h e d a s a r a t i ona l me t h o d o f r e c o ns t r uc t i o n a nd
no t a s a me r e s ur gi c a l t e c h ni que . T h o r o u g h kno wl -
e dg e o f al l i nt e r de pe nde nt f a c t or s a nd a va i l a bl e al -
t e r na t i ve s i s e s s e nt i a l .
Ev a l ua t i o n e nt a i l s k n o wl e d g e o f t h e o r i gi na t i ng
di s e a s e , its pa t h o g e ne s i s , a nd its c ur r e nt s t a t us a t
t h e t i me o f s ur ge r y . T h e di s e a s e c a n b e i nf l a mma t o r y ,
t r a uma t i c , c o nge ni t a l , o r ne o pl a s t i c , a nd its s t a t us
c a n be a c t i ve , pr o gr e s s i v e , r e gr e s s i v e , l a t e nt , o r r e-
s o l v e d. I n l a r ge pa r t , t h e r e s ul t s wi l l d e p e n d upo n
t h i s e v a l ua t i o n a nd c o n s e q u e n t de c i s i o ns . Ade qua t e
pl a nni ng c a n l e a d t o a g o o d " r e c i pi e nt " e a r
c
o r
r e c o ns t r uc t i o n a n d a s o - c a l l e d " dr y e a r " f or s ur ge r y .
Th i s c a n ma k e t h e pr a c t i c a l di f f e r e nc e b e t we e n pe r -
f o r mi ng a t y mpa no pl a s t y or a t y mp a n o ma s t o i d a c -
t o my .
I n a ddi t i o n t o t h e s t a t us o f t h e mi ddl e e a r mu c o s a
a nd t h e unde r l y i ng di s e a s e , c e r t a i n i mpo r t a nt <'ria-
t o mi c e l e me n t s mus t b e c o ns i de r e d.
1. A wi de e a r c a na l . ( A wi de , we l l - a e r a t e d c. n.il
pr o v i de s s o u n d t r a ns mi s s i o n, pr o mo t e s h e a l : i j , ,
a nd f a c i l i t a t e s c l e a ns i ng a nd i ns pe c t i o n. )
2. A vi br a t i ng, i nt a c t t y mpa ni c me mb r a n e .
3. P r o pe r l y f unc t i o ni ng o va l a nd r o und wi n d o w .
4. A we l l - a e r a t e d mi ddl e e a r c a vi t y :
A. Eus t a c h i a n t ube .
B. Ma s t o i d ai r c e l l s .
C. P r o pe r ma s t o i d - mi d d l e e a r c o mmu n i c a t i o n ,
Classifications of Tympanoplasty
Th e r e a r e ma n v s y s t e ms o f c l a s s i f i c a t i o ns t h a t i n
o n e s e ns e o r a no t h e r , c o nt r i b ut e t o a n o ve r a l l unr er -
s t a ndi ng o f t h e s e pr o c e dur e s . Fo r pur po s e s o f iri-
e nt a t i o n t wo us e f ul o n e s a r e de s c r i b e d h e r e , wi t h
t h e e x pe c t a t i o n t h a t t h e r e a de r wi l l r a t i o na l i ze t h m
b a s e d o n h i s o r h e r o wn unde r s t a ndi ng o f t h e pi ib-
l e m. Th i s ne c e s s a r i l y wi l l l e a d t o a g r e e me n t o r c h a l -
l e nge , a nd no t t o a " h a v e t o l e a r n i t " a t t i t ude .
Zo l l ne r a nd Wul l s t e i n c l a s s i f i e d t y mpa no pl a s ' . e s
i nt o t h e f o l l o wi ng five t y pe s :
Type / . T h e t y mpa ni c me mb r a n e i s pe r f o r a t e d; Ihe
o s s i c ul a r c h a i n i s i nt a c t a nd mo b i l e . T h e gr af t i s
pl a c e d a ga i ns t t h e ma l l e us
Type 11. T h e o s s i c ul a r c h a i n i s pa r t i a l l y de s t r o y e d,
b ut its c o nt i nui t y i s pr e s e r v e d. Ei t h e r t h e ma l l e us i s
d a ma g e d ( a na t o mi c t y pe II) o r a n a t t i c o a nt r o t c r a y
T y mp a n o p l a s t y 2 19
h a s b e e n do ne , a nd t h e gr af t i s pl a c e d a ga i ns t t h e
i nc us o r ma l l e us , o r b o t h ( ph y s i o l o gi c t y pe I I ) .
Type 111. T h e ma l l e us a nd i nc us a r e mi s s i ng, a n d
t h e r e i s a n i nt a c t a nd mo b i l e s t a pe s . T h e gr af t i s
pl a c e d a ga i ns t t h e s t a pe s .
Type IV. T h e ma l l e us , i nc us , h e a d, a nd c r ur a of
t h e s t a pe s a r e mi s s i ng. T h e r e i s a mo b i l e f o o t pl a t e .
T h e gr af t i s pl a c e d a ga i ns t t h e f o o t pl a t e .
Type V . Th i s is s i mi l a r to t y pe I V, but t h e r e is a
f i xed f o o t pl a t e . T h e h o r i zo nt a l s e mi c i r c ul a r c a na l i s
f e ne s t r a t e d, a nd t h e gr af t i s pl a c e d a ga i ns t i t a nd t h e
f i xed f o o t pl a t e . P a pa r e l l a di f f e r e nt i a t e s b e t we e n
t y pe s Vo , wh i c h r e f e r s t o t h e c l a s s i c t y pe de s c r i b e d,
a nd V( j , wh i c h r e f e r s t o a pur po s e f ul , c o mpl e t e
s t a p e d e c t o my i n s e l e c t e d c a s e s , wi t h t h e gr af t i nv a -
gi na t e d i nt o t h e o p e n wi n d o w.
Fa r r i o r c l a s s i f i e d t y mpa no pl a s t y a c c o r di ng t o t h e
b a s i c pa t h o l o gi c a n a t o my a t t h e c o mpl e t i o n o f t h e
s ur ge r y . He i de nt i f i e d t h e f o l l o wi ng t y pe s :
. Type I . T y mp a n i c me mb r a n e r e c o ns t r uc t i o n wi t h
a n i nt a c t o s s i c ul a r c h a i n.
Type II. Re c o ns t r uc t i o n of a n e w t y mpa ni c me m-
b r a ne i n its na t ur a l po s i t i o n.
Type III. Re c o ns t r uc t i o n of a n e w t y mpa ni c me m-
b r a ne o n t o p o f a mo b i l e s t a pe s . Th i s i s di v i de d i nt o
t h e f o l l o wi ng s ub c a t e go r i e s :
I I I Cl a s s i c .
Il l I GI n c u s gr a f t .
Il l 1 G MI n c u s gr af t t o ma l l e us .
Il l MG Ma l l e u s h e a d gr af t .
III B G B o n e gr af t .
HI P ORP P a r t i a l o s s i c ul a r r e pl a c e me nt pr o s -
t h e s i s .
Type IV. Re c o ns t r uc t i o n of a n e w t y mpa ni c me m-
b r a ne a n d c o l ume l l a o r f o o t pl a t e o f s t a pe s . Th i s i s
di v i de d i nt o t h e f o l l o wi ng s ub c a t e go r i e s :
I VCl a s s i c .
I V I GI n c u s gr af t
I V MG Ma l l e u s gr af t .
I V B G B o n e gr a f t .
I V CGCa r t i l a g e gr a f t .
I V T O R P T o t a l o s s i c ul a r r e pl a c e me nt pr o s -
t h e s i s .
Type V . Re c o ns t r uc t i o n of t h e t y mpa ni c me m-
b r a ne , e i t h e r o v e r a f i s t ul a i n t h e h o r i zo nt a l s e mi c i r -
c ul a r c a na l o r wi t h s e c o nda r y f e ne s t r a t i o n o f t h e
h o r i zo nt a l s e mi c i r c ul a r c a na l .
P r o c e dur e s t o be pe r f o r me d, e i t h e r a l o ne o r i n
c o mb i na t i o n, i nc l ude t h e f o l l o wi ng:
1. T y mp a n i c me mb r a n e s my r i n g o p l a s t y / t y mp a -
no pl a s t y .
2. Os s i c ul a r c h a i nt y mpa no pl a s t y / o s s i c ul o pl a s t y .
3 . La b y r i nt h i ne wi n d o ws t y mp a n o p l a s t y wi t h
s t a pe de c t o my
4. Ae r a t i o n f a c t o r s e us t a c h i a n t ub e ( P E t ub e ) ,
ma s t o i d ai r c e l l s , ma s t o i d mi ddl e e a r c o mmu n i c a t i o n
( ma s t o i d o t o my / ma s t o i d e c t o my ) .
5. T y mp a n o ma s t o i d c a v i t y t y mp a n o ma s t o i d e c -
t o my .
A n u mb e r o f gr a f t s a n d ma t e r i a l s c a n be us e d i n
a t y mpa no pl a s t y . F o r t h e pur po s e s of a n o ve r a l l
c o nc e pt , s o me b a s i c a s pe c t s a r e de s c r i b e d h e r e .
Kn o wl e d g e o f t h e s e e l e me n t s i s e s s e nt i a l a nd f ur t h e r
s t udy i s r e c o mme n d e d , e s pe c i a l l y i n t h e s e da y s wh e n
t h e s ur g e o n mus t " s wi m i n a s e a of g a dg e t s . " I t i s
o f p a r a mo u n t i mpo r t a nc e t o r e me mb e r a t al l t i me s
t ha t t h e s ur g e o n i s r e s po ns i b l e t o t h e pa t i e nt . Ma n-
uf a c t ur e r s ( no ma t t e r h o w de di c a t e d a nd e t h i c a l ) a r e
r e s po ns i b l e t o a b o a r d of di r e c t o r s a nd ul t i ma t e l y t o
t h e s t o c kh o l de r s . Al t h o u g h i t i s e s s e nt i a l t o wo r k
s i de by s i de wi t h i ndus t r y f or t h e go o d o f t h e pa t i e nt ,
t h e de c i s i o n o f wh a t t o us e a n d h o w t o us e i t b e l o ng s
t o t h e s ur g e o n.
Grafts
Gr a f t s a r e c l a s s i f i e d b y t h e r e l a t i o ns h i p b e t we e n
t h e d o n o r a n d t h e r e c i pi e nt i nt o t h e f o l l o wi ng c a t e -
go r i e s :
1 . Aut o gr a f t ( a dj e c t i v e , a ut o l o g o us ) . D o n o r a nd
r e c i pi e nt a r e o f t h e s a me o r g a ni s m.
2. l s o gr a f t ( i s o ge ne i c ) . D o n o r a nd r e c i pi e nt a r e
t wi ns ( wi t h t h e s a me g e n o t y p e ) .
3. Al l ogr a f t o r h o mo g r a f t ( a l l o ge ne i c , h o mo l o -
go us ) . D o n o r a nd r e c i pi e nt h a v e di f f e r e nt g e n o t y p e s .
4. Xe no gr a f t or h e t e r o gr a f t ( x e no g e ne i c , h e t e r o l -
o g o us ) . D o n o r a nd r e c i pi e nt a r e di f f e r e nt s pe c i e s .
I n a ddi t i o n t o t i s s ue s , o t h e r s o ur c e s a nd ma t e r i a l s
a r e a va i l a bl e . T h e y i nc l ude pl a s t i c , me t a l s , a nd c e -
r a mi c s ( a l l o pl a s t i c ma t e r i a l s ) ; a nd de na t ur e d a ni ma l
s ki n ge l a t i n, f i l m ( Ge l f i l m) , a nd s p o n g e ( Ge l f o a m) .
I n o r de r t o a c h i e v e a s a f e , l o ng- t e r m gr af t , a ddi t i o na l
c r i t e r i a mu s t b e c o ns i de r e d.
1. Bi o c o mpa t i b i l i t y t h e r e a c t i o n of t h e i mpl a nt i n
t h e b o dy ( s uc h a s pr e s e nc e o r a b s e n c e o f c y t o t o xi c -
i t y) , a nd i nf l ue nc e o f t h e b o dy o n t h e i mpl a nt ( f or
e x a mpl e , de gr a da t i o n) .
2. Bi o f unc t i o na l i t y s y mb i o s i s o f t h e i mpl a nt wi t h
t h e i mpl a nt s i t e .
I n t e r ms of its i nt e r a c t i o n wi t h t h e b o dy , a ma t e r i a l
c a n be :
1. Bi o i n e r t n o r e a c t i o n of t h e s ur f a c e t o t h e b o dy
(at mo s t a s ma l l , f i br ous c a ps ul e i s s e e n) .
2. Bi o t o l e r a nt g o o d c a ps ul e a r o und i t wi t h o ut
s i gns o f ma r ke d c e l l ul a r a c t i vi t y ( s uc h a s gi a nt c e l l s )
3 . Bi o a c t i v e b o ndi ng o f t h e ma t e r i a l wi t h t h e
s ur r o undi ng t i s s ue .
2 2 0 T y mp a n o p l a s t y
Grafting of the Tympanic
Membrane
T h e t y mp a n i c me mb r a n e h a s t h r e e l a y e r s : ( 1) a n
o ut e r ( l a t e r a l ) s t r a t i f i e d s q u a mo u s e pi t h e l i um ( c o nt i n-
uo us wi t h t ha t of t h e e a r c a na l ) ; ( 2) a mi ddl e c o nne c -
t i ve t i s s ue c o r e c o nt a i ni ng c o l l a ge n a nd e l a s t i c f i ber s
( pl us t h e v a s c ul a r e l e me nt s ) ; a nd ( 3) a n i nne r l ayer
( c o nt i nuo us wi t h t ha t o f t h e mi ddl e e a r muc o pe r i o s -
t e um) .
P e r f o r a t i o ns t h a t h e a l s p o n t a n e o u s l y t e nd t o e x-
c l ude t h e c o nne c t i v e t i s s ue l a y e r ( mo n o me r i c me m-
b r a ne ) . T h o s e me mb r a n e s t h a t do not h e a l t e nd t o
h a v e i ngr o wt h o f t h e o ut e r s q u a mo u s e pi t h e l i um
c o v e r i ng t h e e dg e s o f t h e pe r f o r a t i o n. T h e a i m o f
gr a f t i ng i s a t r ul y a n a t o mi c r e c o ns t r uc t i o n. T h e c ol -
l a ge n l a y e r pl a c e d a s a gr af t r e i ns t a t e s t h e mi ddl e
l a ye r , a l l o ws e pi t h e l i a l c e l l s t o mi gr a t e , r e - e s t a bl i s h e s
c o nt i nui t y , a n d pe r mi t s t h e me mb r a n e t o r e c o v e r its
vi br a t o r y c h a r a c t e r i s t i c s . Th i s s uppo r t s t h e c o nc e pt s
o f r e i nf o r c i ng mo n o me r i c me mb r a n e s a nd pe e l i ng
t h e e dg e s of a pe r f o r a t i o n be f o r e gr a f t i ng.
Tissues and Materials
Skin. S ki n i s ve r y us ef ul f or c o v e r i ng r a w a r e a s i n
ma s t o i d b o wl s a nd me a t o pl a s t y . I t a l s o pr o v i de s
c o v e r a ge a nd, a t t i me s , va s c ul a r i t y (in pe di c l e d
gr af t s ) o v e r c o l l a ge n gr a f t s ; t h i s gi v e s a ddi t i o na l
t h i c kne s s a nd, mo r e i mpo r t a nt l y , pr o t e c t s t h e gr aft
f r om i nf e c t i o n a nd gr a nul a t i o n t i s s ue . I t mus t be
r e me mb e r e d t ha t a fr ee c o l l a ge n gr af t ( f or e x a mpl e ,
f a s c i a ) h a s no bl o o d s uppl y o f its o wn ( wh e n or i gi -
na l l y pl a c e d) , a nd i s an e a s y pr e y for i nl c c t i o n .inc.1
gr a nul a t i o n t i s s ue . As us e f ul a s s ki n ma v be , h o u -
e ve r , i t do e s not r e pl a c e c o l l a ge n gr a f t s . P l a c e d bv
i t s el f as s o l e c o v e r a g e of a pe r f o r a t i o n, i t i s d o o me d
t o f a i l ur e . S ki n c a n be o b t a i ne d a s a s pl i t - t h i c kne s s
gr af t ( 0. 003 t o 0. 004 c m) f r om a no n- h a i r - b e a r i ng
a r e a f r om t h e uppe r a r m, f o r e a r m, t h i gh , o r a bdo -
me n, by us i ng a d e r ma t o me ( Da S i l v a - Do v a l - S i l v e r )
or a pl a i n r a zo r b l a de on a s t r a i gh t c l a mp ( Fi g. 1 2 -
M ) . I t c a n a l s o be a f ul l - t h i c kne s s gr af t f r om t he
po s t a ur i c ul a r r e gi o n ( Fi g. 1 2 - 1 8 ) o r t h e po s t e r i o r
c a na l s ki n ( f or e x a mp l e , vi a a L e mpe r t 11 i nc i s i on
[ Fi g. 1 2 - 1 C] ) , or f r o m t h e me di a l c a na l s ki n a s a f r ee
or pe di c l e d gr af t . P e di c l e d s ki n gr a f t s h a v e t h e di s-
a dv a nt a g e o f b e i ng t h i c k a n d c u mb e r s o me t o wo r k
wi t h , but t h e y h a v e t h e i r o wn b l o o d s uppl y
Collagen. S o u r c e s of c o l l a ge n a r e ma i nl y t h e f as ci a,
t h e pe r i c h o ndr i um, a nd t h e v e i ns . T h e mo s t c c t n-
mo n l y us e d f a s c i a i s t h e t e mpo r a l , wh i c h i s a va i l a bl e
vi a t h e s a me a p p r o a c h i nc i s i o n or a s ma l l s e pa r a t e
i nc i s i o n, but i n t h e s a me o pe r a t i v e f i el d ( Fi g. 1 2 - 1 D ,
E) . I t i s i mpo r t a nt t o o bt a i n f a s c i a pr o pe r a nd no t t h e
l a y e r o f a e r o l a r c o nne c t i v e t i s s ue o v e r l y i ng it, t h e s o-
c a l l e d " f o o l ' s f a s c i a " ( t h e l a t t e r a l s o h a s c o l l a ge n a nd
c a n be us e d f or gr a f t i ng) . P e r i c h o ndr i um c a n a l s o be
o b t a i ne d e a s i l y f r o m t h e t r a gus a s s uc h , or a s a
c a r t i l a ge - pe r i c h o ndr i um gr af t ( s e e Ch a p t e r 1 0) . I t ct. n
a l s o c o me f r o m c o nc h a l c a r t i l a ge .
A ve i n f r o m t h e do r s um of t h e h a nd a l s o i s e a s i l y
o b t a i na b l e ( s e e Ch a p t e r 13) . I n a ddi t i o n, a l l o ge ne i c
( h o mo l o g o u s ) pe r i c h o ndr i um f r om t h e t i bi a , s e pt um,
c o s t o c h o ndr a l c a r t i l a ge , a nd s o o n c a n b e us e d, a s
we l l a s a l l o ge ne i c dur a ma t e r , a mni o t i c me mb r a n ; ,
a nd c o r ne a . T h e a ut h o r s h a v e no e x pe r i e nc e wi t h
t h e l as t t h r e e ; r e po r t s o n t h e i r us e , a s we l l a s c n
o t h e r t i s s ue s ( s uc h a s h e a r t v a l v e s ) , a r e no t de f i ni t i ve .
Al l o ge ne i c t y mpa ni c me mb r a n e gr a f t s a r e ve r y
s uc c e s s f ul ( unde r t h e pr o pe r c i r c ums t a nc e s ) , a nd
r e pr e s e nt a g o o d a na t o mi c a nd f unc t i o na l a l t e r na t i v e .
A l o ng- t e r m d r a wb a c k i s t h a t of vi r us e s l i vi ng i n
d o n o r t i s s ue ; t h i s mi gh t c o mp r o mi s e t h e us e c f
a l l o ge ne i c gr a f t s i n t h e f ut ur e .
T h e i deal gr af t ma t e r i a l wo u l d be pur e c o l l a ge i
a nd e l a s t i c f i be r s c a pa b l e o f pr o v i di ng t h e mi ddl e
l a ye r , b e c o mi n g i nc o r po r a t e d t o t h e me mb r a n e , a d
a l l o wi ng a nd f a vo r i ng e pi t h e l i a l mi gr a t i o n.
Xe n o g e n e i c ( h e t e r o l o g o us ) ma t e r i a l s , s uc h as b i -
vi ne dur a ma t e r , a r e c ur r e nt l y b e i ng e v a l ua t e d S y
s o me g r o ups a nd, i f s uc c e s s f ul , c o ul d e v e nt ua l v
b e c o me a va i l a bl e .
Grafting of the Ossicular Chain
I h o s e t h r e e i nl c r l o c kc d o s s i c l e s ( unde r t h e pr o t e \ -
l i ve i nf l ue nc e ol I wo mi ddl e e a r mus c l e s ) , wh i c i
t r a ns mi t s o und wa v e s a s a uni t f r om t h e t v mp a m:
me mb r a n e t o t h e o va l wi n d o w, c a n be pa r t l y t :
t ot al l y f i xa t e d, di s l o c a t e d, or de s t r o y e d. T h e pur po s
1
of gr a f t i ng i s t o r e - e s t a bl i s h f unc t i o na l c o nt i nui t / -
f r om t h e t y mpa ni c me mb r a n e t o t h e o va l wi n d o v
I de a l l y, gr a f t s a nd ma t e r i a l s s h o ul d b e e a s i l y po s
t i one d a nd s h a pe d; b e r e a di l y a va i l a bl e ; c a us e mi ni
mal t i s s ue r e a c t i o n; r e ma i n s t a bl e wi t h i nf e c t i o n; a nc
r e ma i n i n po s i t i o n, no t e x t r udi ng o r d a ma g i n g t h-
t y mpa ni c me mb r a n e . Co mmo n c o mpl i c a t i o ns in-
c l ude r e s o r pt i o n, r e j e c t i o n, f i xa t i on, di s pl a c e me nt ,
a nd e x t r us i o n. A br i e f o ve r a l l a s s e s s me n t f o l l o ws ; a
c o mp r e h e n s i v e de s c r i pt i o n i s o ut s i de t h e s c o p e o '
t h i s b o o k.
FIGURE 12-1
2 2 2 T y mp a n o p l a s t y
Tissues and Materials
Ossicles and Cortical Bone. Os s i c ul a r a n d cor t i cal
b o n e ( a ut o l o g o us o r a l l o ge ne i c ) gr a f t s a r e a va i l a bl e ,
a r e e a s i l y s c ul pt ur e d, a r e t h e b e s t t o l e r a t e d, a nd ar e
l eas t l i ke l y t o e x t r ude . Th e i r d r a wb a c k s i nc l ude di s -
pl a c e me nt , r e f i xa t i on, a nd a t e n d e n c y t o a dh e r e t o
t h e ma r g i ns o f t h e o va l wi n d o w, t o e x t r ude o r
di s pl a c e i f t h e r e i s no ma l l e us ( t h e l a t t e r i s c o mmo n
t o al l pr o s t h e s e s ) , a nd t o a t r o ph y .
Cartilage. Ca r t i l a ge ( a ut o l o g o us or a l l o ge ne i c )
gr a f t s a r e a va i l a bl e , a r e e a s i l y s h a p e d a nd we l l tol -
e r a t e d, a nd s h o w ve r y l ittl e e x t r us i o n. Ho we v e r ,
c a r t i l a ge l a c ks s t i f f ne s s , wo r k i n g we l l a t t h e o ns e t
but t e ndi ng t o l os e r i gi di t y a nd "f al l a pa r t " af t er a
f ew y e a r s ( t h i s i s s uppo r t e d by s o me r e po r t s but
de ni e d by o t h e r s ) . I n a ddi t i o n, c a r t i l a ge t ol e r a t e s
i nf e c t i on po o r l y .
Plastics. Te f l o n is us e d pr i ma r i l y as a pi s t o n f or a
s t a pe de c t o my . Al t h o ug h t h i s s ol i d pl a s t i c h a s s mo o t h
s ur f a c e s , i t h a s no l o ng- t e r m i nf l a mma t o r y r e a c t i o n
An e x c e l l e nt ma t e r i a l wh e n pr o pe r l y us e d, i t i s not
ef f i ci ent a s a T O R P ( t ot al o s s i c ul a r r e pl a c e me nt pr os -
t h e s i s ) . Te f l o n i s a g o o d ma t e r i a l f or PE t ub e s .
P l a s t i po r e ( h i gh - de ns i t y po l y e t h y l e ne ) , wh i c h h a s
b e e n us e d i n T O R P s a nd P O R P s , i s st i l l a s ub j e c t of
c o nt r o v e r s y . Its i ni t i al l y i mpr e s s i v e s uc c e s s wa s fol -
l o we d b y a n e qua l l y un i mp r e s s i v e a nd di s a ppo i nt i ng
f ai l ur e i n t e r ms of e x t r us i o n r a t e . P l a s t i po r e i s e a s i l v
a va i l a bl e ; i s not s o r i gi d a s o s s i c l e s or c e r a mi c s ; c a n
be e a s i l y s h a p e d a c c o r di ng t o ne e d; i s h i o me c h a ni -
cal l y s o und; i s r e l a t i ve l y e a s y t o po s i t i o n a nd s t e r i l i ze
( t hi s r e qui r e s s ki l l t o do pr o pe r l y ) ; d o e s no t a dh e r e
t o t h e ma r gi ns of t h e ova l wi ndow- ; a nd i s a n ef f i ci ent
s o und c o nduc t o r . Its dr a wb a c ks ar e t hat i t c a us e s a
f or ei gn b o dy r e a c t i o n i n t h e mi ddl e e a r , a nd c a n
e x t r ude a nd s l i p. T h e h i gh e x t r us i o n r a t e i s s i gni f i -
c a nt l y di mi ni s h e d by pl a c i ng c a r t i l a ge o v e r t h e pr os -
t h e s i s ( b e ne a t h t h e t y mpa ni c me mb r a n e o r t y mpa ni c
me mb r a n e gr af t , i de a l l y unde r t h e ma l l e us ) . S l i ppa ge
a t t h e o va l wi n d o w ( wh e n pl a c e d o v e r i nt a c t , mo bi l e
f o o t pl a t e s ) c a n be r e duc e d by c r e a t i ng a s ma l l o pe n-
i ng i n t h e f o o t pl a t e , t h r o ugh wh i c h a T O R P wi t h a
pe g i n its di s t a l e nd i s i ns e r t e d ( de s c r i b e d b e l o w) .
P O R P s c a n be s t a bi l i ze d by ma k i n g a sl it t h a t a l l o ws
a mo r e s t a b l e c o nt a c t wi t h t h e s t a pe s h e a d. I n s pi t e
o f t h e s e d r a wb a c k s , T O R P s a nd P O R P s ma d e o f
P l a s t i po r e wo r k ve r y we l l i n pr o pe r l y s e l e c t e d c a s e s
a nd r e ma i n a first c h o i c e un d e r t h e pr o pe r c o ndi -
t i ons .
Ceramics. Ce r a mi c s , i no r g a ni c c r ys t a l ma t e r i a l s
pr o duc e d a t h i gh t e mpe r a t ur e s , a r e t h e " i n " ma t e -
r i al s i n o s s i c ul o pl a s t y a nd r e c o ns t r uc t i v e e a r s ur ge r y
T h e y h a v e b e e n us e d s uc c e s s f ul l y i n o r t h o pe di c s a nd
de nt i s t r y . Gl a s s - c e r a mi c s a r e pr o duc e d by t h e r m il l y
t r e a t i ng gl a s s , o b t a i ni ng a po l y c r y s t a l l i ne mi c r o s t j uc -
t ur e . T h e a d v a n t a g e s o f t h e s e d e n s e ma t e r i a l s are
t hat t h e y a r e b i o c o mpa t i b l e , b i o f unc t i o na l , e a s y t o
pl a c e a nd ma ni pul a t e , a nd, r e po r t e dl y , e a s y t o
s h a pe . T h e a ut h o r s h a v e f o und, h o we v e r , t h a t t l e y
a r e h a r d t o r e s h a pe a nd s o me t i me s br e a k, e v e n wl e n
s h a p e d wi t h a d i a mo n d dr i l l unde r c o ns t a nt i r r i ga-
t i on. Al t h o ug h pr o mi s i ng, t h e s e ma t e r i a l s h a v e still
t o wi t h s t a nd t h e t es t of t i me i n o t o l o gy . Ev i de nc e
s ugge s t s t h a t t h e y pr o b a b l y wi l l ; t i me a nd e x pe r i e nc e
s h o ul d tel l us ( no t t h e ma nuf a c t ur e r s ) . I n pr o s t h e t i c s ,
t h e mo s t c o mmo n l y us e d c e r a mi c i s t h e b i o a c t i v e ,
po r o us , c r y s t a l l i ne f or m o f c a l c i um ph o s ph a t e . Bi o-
gl a s s i s a n e x a mp l e of gl a s s a nd c e r a vi t a l , a f or m of
c a l c i um ph o s ph a t e wi t h t h e s a me c a l c i um- t o - ph c s -
ph a t e r at i o a s t h e na t ur a l b o n e mi ne r a l h y dr o x y -
a pa t i t e , wh i c h i s pe r h a ps t h e mo s t b i o c o mpa t i b l e
ma t e r i a l a va i l a bl e . T h e e s s e nt i a l a i m i n pr o s t h e t i c s i s
t o o bt a i n ma t e r i a l s t h a t a r e a s c l o s e t o na t ur a l i s
po s s i b l e , f ul f i l l i ng t h e c o nc e pt of " r e pl a c i ng wj h
s a me . "
Plastics. S i l a s t i c i s c o mmo n l y us e d i n mi ddl e e i r
s ur ge r y a s t hi n s h e e t s a nd a s PE t ub e s . I t i s bi o i ne r i
( t hat i s , i t e l i c i t s no l o ng- t e r m i nf l a mma t o r y r e a c t i o n) ;
its us e s a r e ( 1) t o pr e v e nt a d h e s i o n s wh e n pl a c e d
o v e r r o ugh , l a c e r a t e d s ur f a c e s o r s ur r o undi ng
pr o s t h e s e s o r gr a f t s , t h us a l l o wi ng a n a e r a t e d o pe n
s pa c e ; a nd ( 2) t o a v o i d a dh e s i o ns b e t we e n di f f e r e nt
mi ddl e e a r s t r uc t ur e s t hat c o ul d c o mp r o mi s e t h e r
f unc t i o n. I f no t po s i t i o ne d pr o pe r l y o r t r i mme d
s mo o t h l y a t t h e e d g e s , i t c a n e x t r ude . S pe c i f i c us e s
a r e de s c r i b e d i n v a r i o us c h a pt e r s o f t h i s b o o k
Celfonm. Ge l f o a m ( de na t ur e d a ni ma l s ki n ge l a t r.)
i s us e d uni v e r s a l l y i n o t o l o gi c s ur ge r y . Th i s a b s o r b -
a bl e ge l a t i n is a v a i l a b l e as a s!> r il e po wde r , s po n; e,
or fil m ( 0. 07 5 mm t h i c k) . On l v t h e l ast t wo f o r ms ; r e
us e d. T h e s t e r i l e s p o n g e f or m, wh i c h i s c a pa b l e >(
a b s o r b i ng a nd h o l di ng wi t h i n i t s me s h e s ma n y tirr, ' s
its we i gh t i n wh o l e b l o o d, i s a b s o r b e d c o mpl e t e l y n
f our t o six we e k s . It i s us e d as a h e mo s t a t i c a ge r t ,
t o pa c k t h e mi ddl e e a r c a vi t y , t o a ppl y pr e s s u- e
b e t we e n t h e gr af t a nd t h e t y mpa ni c me mb r a n e , o
pr o mo t e a mi l d i nf l a mma t o r y r e a c t i o n n e e d e d :>.
c e r t a i n po i nt s , a nd as a v e h i c l e f or a nt i bi o t i c - s t e r o
1
i
s o l ut i o ns . Ge l f i l m i s an a ppa r e nt l y br i t t l e f i l m t h t
b e c o me s sof t a nd r ub b e r y wh e n mo i s t e ne d i n s a l i n .
I t i s us e d t o di s c o ur a ge a d h e s i o n s , s uc h as i n s e p:
r a t i on o f t h e i nc udo s t a pe di a l j o i nt f r om t h e t y mpa n. c
me mb r a n e . I n its dr y f or m, Ge l f o a m s h o ul d be dt
c o mp r e s s e d ; wh e n s a t ur a t e d, i t s h o ul d be s que e z e i
i n o r de r t o r e mo v e ai r b ub b l e s . Ge l f i l m i s no t us ef t , !
a s a gr af t f or t y mp a n i c me mb r a n e pe r f o r a t i o ns .
Ge l f o a m s we l l s a s i t a b s o r b s f l ui d. As i t e x p a n d ?
i t i mpi ng e s on ne i g h b o r i ng s t r uc t ur e s ( wh i c h i s wh i
T y mp a n o p l a s t y 2 2 3
i t wo r k s we l l i n f i l l i ng t h e mi ddl e e a r c a vi t y wh e n
a n unde r l a y gr af t i s pl a c e d) . Ge l f o a m po t e nt i a l l y ma y
b e c o me a f o c us of i nf e c t i o n.
Ti ssue Adhesi ons ( "Gl ue s ") . Gl u e s h a v e b e e n t h e
dr e a m o f ma n y o t o l o gi s t s f or y e a r s . Hi s t o a c r y l ( c y-
a no b ut y l a c r y l a t e ) a n d Fi br i n, t h e t wo t y pe s t h a t a r e
a va i l a bl e , wo r k f ai r l y a c c e pt a b l y but a r e far f r om
i deal . Ei t h e r t h e y mus t a wa i t t h e t e s t o f t i me o r we
mus t a wa i t a b e t t e r a dh e s i v e . T h e de s c r i pt i o n o f
t h e m i s b e y o n d t h e s c o p e o f t h i s b o o k.
l o o ke d f or ( Fi g. 1 2 - 2 D , E) . T h e t y mpa ni c me mb r a n e
i t s el f ma y be no r ma l , a t r o ph i c , s c l e r o t i c , t h i c k, re-
t r a c t e d, o r a dh e s i v e .
T h e s e c o n o i t i o n s gi v e a n i nde x o f s uc h f a c t o r s a s
t h e unde r l y i ng c a us e , e us t a c h i a n t ub e f unc t i o n, aer -
a t i on, v a s c ul a r i t y o f t h e me mb r a n e , a nd s o o n. Al l
o f t h e s e wi l l a f f e c t t h e gr af t t a ke a nd i nf l ue nc e t h e
s e l e c t i o n o f t h e t y pe o f r e pa i r .
Approach
Myringoplasty-Type I
Tympanoplasty T h e r e a r e n o f i xed r ul e s f or a c h i e v i ng t h e final
pur po s e , wh i c h i s a de qua t e vi s ua l i za t i o n t h r o ugh a n
o pe n c a na l , a l l o wi ng a g o o d a s s e s s me n t a nd r e pa i r .
A my r i ng o pl a s t y a n d a t y pe I t y mp a n o p l a s t y i n- T h e a ppr o a c h s h o ul d pr o v i de a c l e a r vi s ua l i za t i o n
vo l ve r e pa i r o f t h e t y mpa ni c me mb r a n e a l o ne . " My - a r o und t h e b o r de r s o f t h e pe r f o r a t i o n a nd, i de a l l y,
r i ngo pl a s t y " i s t h e t e r m us e d wh e n t h e o pe r a t i o n c l e a r vi s ua l i za t i o n o f t h e e nt i r e a nnul us . Ot o l o gi s t s
do e s no t i nc l ude r a i s i ng f l aps t o e nt e r t h e mi ddl e e a r s h o ul d be c a pa b l e o f a da pt i ng t h e a ppr o a c h t o t h e
c a v i t y , . wh e r e a s a t v pe I t y mpa no pl a s t y i mpl i e s t h e ne e ds of t h e c a s e a nd no t v i c e ve r s a . T h e r e a r e a
o ppo s i t e . Di f f e r e nt ' t y pe s ' o f t y mpa no pl a s t i e s a nd n u mb e r o f s i t ua t i o ns i n wh i c h o n e a ppr o a c h h a s
o s s i c ul o pl a s t i e s i nv o l v e pr o c e dur e s i n t h e di f f e r e nt c e r t a i n a d v a n t a g e s o v e r o t h e r s . T h e y wi l l b e h i gh -
s t r uc t ur e s o f t h e mi ddl e e a r a t o r b e y o n d ( me di a l t o) l i gh t e d wi t h t h e unde r s t a ndi ng t ha t al l gui de l i ne s
t h e t y mp a n i c me mb r a n e . T h e b r o a d t e r m " t y mp a - a r e r e l a t i ve .
no pl a s t y " i s us e d f or a ny pr o c e dur e wh o s e pur po s e T h e a l t e r na t i v e a p p r o a c h e s a r e t h e t r a ns c a na l , t h e
i s t o e r a di c a t e di s e a s e a nd r e c o ns t r uc t t h e h e a r i ng e nda ur a l , a nd t h e po s t a ur i c ul a r . A t r a ns c a na l a p-
me c h a n i s m wi t h o r wi t h o ut t y mpa ni c me mb r a n e pr o a c h i s us e d i n ge ne r a l f or s ma l l pe r f o r a t i o ns , o r
gr a f t i ng. P r o v i de d t ha t al l t h e i nt e r de pe nde nt f a c t or s f or me d i u m po s t e r i o r pe r f o r a t i o ns i n a wi de c a na l
pr e v i o us l y de s c r i b e d a r e unde r c o nt r o l , a n o ve r a l l t ha t a l l o ws a c l e a r vi s ua l i za t i o n o f t h e a nt e r i o r b o r de r
a na l y s i s of t h e r e qui r e d pr o c e dur e i nv o l v e s s e ve r a l of t h e pe r f o r a t i o n. I t i s i na de qua t e for pe r f o r a t i o ns
a s pe c t s . ' h a t a r e l a r ge o r t hat i nv o l v e t h e a nnul us , o r for
T h e a n a t o my o f t h e t y mpa ni c me mb r a n e mus t b e c a s e s t ha t mi g h t ne e d a n a s s o c i a t e d ma s t o i d pr o c e -
c o ns i de r e d. Th i s i nc l ude s not o nl y t h e s i t e a nd e x t e nt dur e . An e nda ur a l a ppr o a c h pr o v i de s g o o d vi s i bi l i t y,
o f t h e pe r f o r a t i o n but a l s o t h e s t a t us o f t h e me mb r a n e e s pe c i a l l y o f t h e po s t e r i o r qua dr a nt s . F o r a nt e r i o r
( a t r o ph i c , a t e l e c t a t i c , wi t h t y mpa no s c l e r o t i c pl a que s , pe r f o r a t i o ns , a n a s s o c i a t e d c a na l pl a s t y i s ne c e s s a r y ,
a nd s o o n ) . Ba s e d o n t h i s i nf o r ma t i o n, a n a ppr o a c h Th i s a ppr o a c h a l l o ws a me a t o pl a s t y i n c a s e s o f a
i s s e l e c t e d, t y pe s of s ki n f l aps (if a ny ) a n d gr a f t i ng s ma l l , t h i c k me a t us . A po s t a ur i c ul a r a p p r o a c h a l s o
ma t e r i a l t o b e us e d a r e c h o s e n, a nd po s i t i o ni ng o f pr o v i de s g o o d vi s i bi l i t y, e s pe c i a l l y o f t h e a nt e r i o r
t h e gr af t i s de c i de d ( unde r l a y unde r t h e me mb r a n e ma r gi n o f t h e t y mpa ni c me mb r a n e : i t a l l o ws t h i s
or o v e r l a y o v e r t h e me mb r a n e ) . v i e w wi t h o ut a c a na l pl a s t y . I t i s us e f ul f or me d i u m
A t y mpa ni c me mb r a n e pe r f o r a t i o n ma y be r e- t o l a r ge pe r f o r a t i o ns a s we l l a s a nt e r o i nf e r i o r pe r f o-
s t r i c t e d t o o n e qua dr a nt a l o n e t h e po s t e r o s upe r i o r , r a t i o ns , wi t h o r wi t h o ut a l t e r a t i o n o f t h e a nnul us .
po s t e r o i nf e r i o r , a nt e r o s upe r i o r , o r a nt e r o i nf e r i o r . A Re ga r dl e s s o f t h e a ppr o a c h , pr e s e r v a t i o n o f t h e a n-
pe r f o r a t i o n o f S h r a pne l l ' s me mb r a n e c o ns t i t ut e s a n nul us ma i nt a i ns t h e mi ddl e e a r s pa c e , pr o v i de s s up-
e x c e pt i o n t o t h i s ; e x pl o r a t i o n i s a dv i s e d i n al l c a s e s . por t , a nd r e duc e s t h e r i s k o f r e t r a c t i o n.
Be c a u s e o f t h e a na t o mi c po s i t i o n o f S h r a pne l l ' s me m- Re v i s i o n s ur ge r y i n ge ne r a l i s d o n e via a n a l t e r na t e
b r a ne , e pi t h e l i a l i ng r o wt h i s a l wa y s a po s s i bi l i t y , i nc i s i o n t h a t a l l o ws a gr af t t o be o b t a i ne d. T h e ma i n
e v e n wi t h a no r ma l a udi o g r a m ( f or e x a mp l e , a " c o n - que s t i o ns i n r e v i s i o ns a r e ( 1) Wh y di d t h e pr o c e dur e
duc t i v e " c h o l e s t e a t o ma ) . A pe r f o r a t i o n a l s o c a n i n- fail i ni t i a l l y? ( 2) Wa s f ai l ur e c a us e d by e x po s ur e ,
vo l ve mo r e t h a n o n e qua dr a nt ( Fi g. 1 2 - 2 A, B) , o r i t c l i ni c a l e r r o r , o r unde r l y i ng di s e a s e ?
ma y i nv o l v e t h e a nnul us . I t c a n b e t ot a l ( Fi g. 1 2 - 2 C) , Wh i c h e v e r a ppr o a c h i s c h o s e n , t h e c a na l s h o ul d
c e nt r a l , o r ma r gi na l . I f t h e r e a r e s e ve r a l pe r f o r a t i o ns , b e s mo o t h a n d t h e r e s h o ul d b e no b o n y o v e r h a ng s ,
unde r l y i ng di s e a s e ( s uc h a s t ub e r c ul o s i s ) s h o ul d be I f t h e a n n ul us i s mi s s i ng, a s ul c us (if ne c e s s a r y )
2 2 4 T y mp a n o p l a s t y
E
FIGURI; 12-2
T y mp a n o p l a s t y 2 2 5
s h o ul d be c r e a t e d ( t o pr e v e nt b l unt i ng) . I f a n a t t i c o-
t o my i s pe r f o r me d, t h e a t t i c mus t be r e i nf o r c e d. I f
t h e e us t a c h i a n t ub e i s dy s f unc t i o na l a PE t ub e s h o ul d
b e c o ns i de r e d.
O n c e t h e a ppr o a c h h a s b e e n s e l e c t e d a nd pe r -
f o r me d a nd t h e t y mpa ni c me mb r a n e i s vi s ua l i ze d,
t h e ne x t de c i s i o n i s t h e c a na l i nc i s i o ns t o us e . ( Be f o r e
e l e v a t i ng t h e f l a ps , a ny t y mpa ni c me mb r a n e wo r k
[ s uc h a s t r i mmi ng t h e e dg e s ] s h o ul d b e pe r f o r me d,
s i nc e i t i s s i mpl e r a t t h i s t i me a n d t h e me mb r a n e i s
i n its na t ur a l po s i t i o n. ) T h e b a s i c pr i nc i pl e i s t o e nt e r
t h e mi ddl e e a r c a v i t y ( t y pe 1 t y mpa no pl a s t y ) i n a
wa y t h a t a l l o ws a de qua t e i ns pe c t i o n o f t h e c a vi t y
a nd e f f i c i e nt pl a c e me nt of a gr af t . T h e a l t e r na t i ve s
a r e ma n y a nd va r y a c c o r di ng t o ne e d a nd pr e f e r e nc e ,
a s we l l a s t h e i ma gi na t i o n of t h e s ur ge o n, A c l a s s i c
po s t e r i o r c a na l f l ap ( 1 a nd 6 o ' c l o c k ve r t i c a l i nc i s i o ns )
of f e r s a de qua t e e x po s ur e i n mo s t (if no t al l ) c a s e s
a nd i s a g o o d a l t e r na t i v e . An a nt e r i o r or a n i nf e r i or
f l ap mi gh t s uf f i c e ( Fi g. 1 2 - 3 A - C) , or a " s wi ng i ng
d o o r " t e c h ni que c a n b e us e d ( Fi g. 1 2 - 3 D , E) . I f s ki n
r e i nf o r c e me nt i s n e e d e d , a pe di c l e d f l ap c a n be
ut i l i ze d. S o me o f t h e mo s t c o mmo n l y us e d f l a ps wi l l
b e de s c r i b e d i n t h e di s c us s i o n o f s pe c i f i c pr o c e dur e s .
T h e y a r e s i mpl y a l t e r na t i v e s a nd a r e no t ne c e s s a r i l y
t h e o nl y c h o i c e s .
Small Central Perforation
T h e e d g e s o f t h e pe r f o r a t i o n a r e t o uc h e d wi t h a
bl unt pi c k mo i s t e ne d i n t r i c h l o r o a c e t i c a c i d ( Fi g. 1 2 -
4/ 1) . Up o n c o nt a c t wi t h t h e a c i d, t h e e dg e s a c qui r e a
wh i t e a ppe a r a nc e . A pa pe r pa t c h ( c i ga r e t t e pa pe r ) i s
a ppl i e d o v e r l y i ng t h e pe r f o r a t i o n ( Fi g. 1 2 - 4 6 ) . I t i s
i mpo r t a nt t o pr e v e nt a ny a c i d f r om f al l i ng i nt o t h e
mi ddl e e a r c a vi t y s i nc e t h i s i s e x t r e me l y pa i nf ul ; t h e
i ns t r ume nt s h o ul d b e ba r e l y mo i s t e n e d . I f t h i s c o m-
pl i c a t i o n o c c ur s , ne ut r a l pH ot i c dr o ps s h o ul d b e
us e d i n c o nj unc t i o n wi t h a n a nt i - i nf l a mma t o r y me d -
i c a t i o n. Th i s do e s no t wo r k al l t h e t i me a nd c a n o nl y
be us e d f or a s ma l l pe r f o r a t i o n i n a h e a l t h y me m-
b r a ne .
Fo r t i ny c e nt r a l pe r f o r a t i o ns , t h e e dg e s c a n be
t r i mme d ( Fi g. 1 2 - 4 C, D) ; a s ma l l t r i a ngl e we d g e wi t h
its b a s e i n t h e a n n ul us i s t h e n c r e a t e d ( Fi g. 1 2 - 4 E) .
T h e a n n u l u s i s e l e v a t e d ( a nt e r o po s t e r i o r e d g e ) a nd
sl i d t o wa r d t h e pr o x i ma l ( no ne l e v a t e d) e dg e , a l l o w-
i ng t h e e dg e s o f t h e t y mpa ni c me mb r a n e t o c o me
t o ge t h e r ( Fi g. 1 2 - 4 F ) . S ma l l pi e c e s o f Ge l f o a m ar e
a ppl i e d o v e r t h e a ppr o x i ma t e d e d g e s
Fo r a ve r y s ma l l c e nt r a l pe r f o r a t i o n t hat r e qui r e s
gr a f t i ng, t h e e dg e s a r e t r i mme d a nd t h e unde r s ur f a c e
o f t h e me mb r a n e i s ge nt l y s c r a pe d. I ns t e a d o f r a i s i ng
a f l ap, a n i nc i s i o n i s ma d e i n t h e mi ddl e of t h e
pe r f o r a t i o n a nd t o wa r d t h e a nnul us ( Fi g. 1 2 - 5 / 1 , B)
T h e t y mp a n i c me mb r a n e i s c a r e f ul l y r e f l e c t e d, a l l o w-
i ng e n o u g h s pa c e t o a ppl y Ge l f o a m i n t h e mi ddl e
e a r a nd a me di a l ( unde r l a y ) gr af t ( Fi g. 1 2 - 5 C) . T h e
t y mpa ni c me mb r a n e i s r e po s i t i o ne d a nd Ge l f o a m i s
a ppl i e d o v e r i t ( Fi g. 1 2 - 5 D ) .
Fo r a s ma l l c e nt r a l pe r f o r a t i o n, a n unde r l a y gr af t
i s pl a c e d t h r o ug h t h e pe r f o r a t i o n ( Fi g. 1 2 - 5 E) , T h e
e dg e s o f t h e pe r f o r a t i o n a r e t r i mme d me t i c ul o us l y ,
a n d t h e unde r s ur f a c e o f t h e me mb r a n e i s ge nt l y
s c r a pe d ( f r e s h e ne d) ; t h i s i nc l ude s c l e a ns i ng (if
n e e d e d ) o f t h e ma n u b r i u m. T h e mi ddl e e a r c a vi t y i s
f i l l e d wi t h c o mp r e s s e d Ge l f o a m ( Fi g. 1 2 - 5 F ) a nd a
f as ci a gr af t i s pl a c e d t h r o ug h t h e pe r f o r a t i o n, ma k i n g
s ur e t h a t t h e e dg e s o f t h e pe r f o r a t i o n a r e o v e r l a ppe d
by t h e gr af t by mo r e t h a n 3 0 %. I f n e e d e d , a pi e c e o f
f as ci a i s pl a c e d b e t we e n t h e t y mpa ni c me mb r a n e a nd
t h e l o ng pr o c e s s o f t h e ma l l e us . T h e ma l l e us h a ndl e
c a n be de - e pi t h e l i a l i ze d a n d a pi e c e o f f as ci a pl a c e d
l a t e r a l l y.
T h e s e pr o c e dur e s r e qui r e a h e a l t h y , we l l - va s c ul a r -
i zed t y mpa ni c me mb r a n e .
Overlay Technique
in Central Perforation
Critical Points
1. Co mp ' e t e de - e pi t h e l i a l i za t i o n.
2. A we l l - de f i ne d, we l l - pl a c e d a nt e r i o r t y mpa no -
me a t a l a ngl e j unc t i o n.
3. At t a c h me n t o f gr af t t o h a ndl e o f ma l l e us .
Procedure
A po s t a ur i c ul a r a p p r o a c h h a s b e e n s e l e c t e d a nd a
t e mpo r a l f as ci al gr af t o b t a i ne d. T h e i nc i s i o n o f t h e
po s t e r i o r c a na l i s ma d e a t t h e j unc t i o n o f t h e l at er al
a nd mi ddl e t h i r ds o f t h e c a na l . Th i s pr o c e dur e in-
v o l v e s r e mo v a l o f t h e c a na l s ki n f r om t h i s j unc t i o n
d o wn t o 2 mm l a t e r a l t o t h e a n n ul us ( e x c e pt i ng t h e
a r e a o f s ki n c o nt a i ni ng t h e v a s c ul a r s t r i p) . Ve r t i c a l
i nc i s i o ns a r e ma d e a t 10 a nd 1 o ' c l o c k ( Fi g. 1 2 - 6 / 1 ) .
T wo c i r c umf e r e nt i a l i nc i s i o ns a r e ma d e , t h e first 2
mm l a t e r a l t o t h e a n n u l u s ( e x c e pt i ng t h e a r e a be -
t we e n 10 a nd 1 o ' c l o c k) a nd t h e s e c o nd a t t h e j unc t i o n
of t h e l a t e r a l a nd mi ddl e t h i r ds of t h e c a na l . ( Th i s i s
a n e x t e ns i o n o f t h e c a na l i nc i s i o n a l o ng t h e wh o l e
c i r c umf e r e nc e . ) T h e s ki n i s c a r e f ul l y e l e v a t e d i n o ne
pi e c e a nd pr e s e r v e d. A c a na l pl a s t y i s d o n e i f ne e de d.
T h e t y mpa ni c me mb r a n e i s me t i c ul o us l y de - e pi t h e -
Text continued on page 230
Tympanoplasty 227
E
fiCURE 12-4
..... ----------------.,
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1
rieUR!' 12-3
226 Tympanoplasty
2 2 8 T y mp a n o p l a s t y
T y mp a n o p l a s t y 2 2 9
2 30 T y mp a n o p l a s t y
l i al i zed wi t h a j o i nt or No . 2 c a na l kni f e or s ma l l
c ur e t s ( Fi g. 1 2 - 6 8 ) . T h e mi ddl e e a r i s f i l l ed wi t h
c o mp r e s s e d Ge l f o a m, a nd t h e gr af t i s no t c h e d t o fit
a r o und t h e ma n u b r i u m ( Fi g. 1 2 - 6 C) . ( T h e ma nu-
br i um i s de - e pi t h e l i a l i ze d a nd c l e a ns e d. ) T h e gr af t i s
pl a c e d e mb r a c i n g t h e ma nub r i um; i f n e e d e d , a pi e c e
o f f as ci a i s pl a c e d o v e r t h e ma l l e us h a n d l e ( Fi g. 1 2 -
6 D ) . T h e s ki n gr af t i s t h e n r e t ur ne d, o v e r l a ppi ng t h e
f as ci a f or a f e w mi l l i me t e r s . S pe c i a l c a r e mus t be
o b s e r v e d a nt e r i o r l y i n o r de r t o a v o i d b l u n t mg o f t h e
gr af t i n t h e a nt e r i o r t y mp a n o me a t a l a ngl e . T h e c a na l
i s pa c ke d, us ua l l y wi t h Ge l f o a m i n t h e me di a l t wo
t h i r ds ( Fi g. 1 2 - 6 F ) . I n c a s e s wh e r e t h e r e i s no f i br ous
a nnul us , t h e s ul c us s h o ul d be c h e c k e d ; i f s h a l l o w, i t
c a n be dr i l l e d wi t h a s ma l l bur . I nc i s i o ns a r e c l o s e d
wi t h a ppr o pr i a t e s ut ur e s a nd a dr e s s i ng i s a ppl i e d.
Probl ems and Compl ications
Bl unt i ng o f t h e a nt e r i o r t y mp a n o me a t a l a ngl e i s
t h e mo s t f e a r e d c o mpl i c a t i o n, a nd us ua l l y o c c ur s
wh e n t h e r e i s no a n n ul us a nd no s ul c us . Dr i l l i ng o f
t h e s ul c us i s h e l pf ul . Ti gh t pa c ki ng a t t h i s a ngl e i s
i mpo r t a nt ( r o s e b ud pa c ki ng wi t h O we n ' s s i l k wo r ks
qui t e we l l f or t h i s pur po s e ) . La t e r a l i za t i o n o f t h e
gr af t ( l at er al di s pl a c e me nt ) h a p p e n s l e s s f r e que nt l y
i f t h e t i p o f t h e ma l l e us h a ndl e i s pl a c e d o v e r t h e
f as ci a. Re s i dua l c h o l e s t e a t o ma o c c ur s wh e n dc - e pi -
t h e l i a l i za t i o n o f t h e t y mpa ni c me mb r a n e i s i nc o m-
pl e t e . Re pe r f o r a t i o n a nt e r i o r l y i s e s pe c i a l l y c o mmo n
i f t h e r e i s no a nnul us . Th i s i s i nv o l v e d wi t h s uppo r t
of t h e gr af t ( by t h e a nnul us ) a nd v a s c ul a r i za t i o n i n
t h e a r e a
Underlay Graft for Posterior
Perforation in Atrophic Membrane
Us i ng a n e nda ur a l a ppr o a c h , a t e mpo r a l f as ci a
gr a f t ( by L e mp e r t I i nc i s i o n) a nd a s ma l l s ki n gr af t
( by a L e mp e r t I I i nc i s i o n) h a v e b e e n o b t a i ne d. T h e
t y mpa ni c me mb r a n e i s vi s ua l i ze d; i f ne c e s s a r y , a
c a na l pl a s t y i s d o n e . T h e e d g e s o f t h e pe r f o r a t i o n a r e
t r i mme d, t h e unde r s ur f a c e o f t h e me mb r a n e i s ge nt l y
s c r a pe d, a nd t h e me mb r a n e i s de - e pi t h e l i a l i ze d.
Co mp l e t e de - e pi t h e l i a l i za t i o n mus t be d o n e i f a s ki n
gr af t i s t o be us e d. I f t h e me mb r a n e i s a t r o ph i c ,
h o we v e r , c o mp l e t e de - e pi t h e l i a l i za t i o n mi gh t be
mo r e h a r mf ul t h a n us e f ul ( a n unde r l a y gr af t i s be i ng
us e d) b e c a us e o f t h e po t e nt i a l f or t e a r s .
I f a PE t ub e i s b e i ng c o ns i de r e d, t h i s i s t h e t i me
t o s e l e c t a n a r e a a nd pl a c e it.
I n t hi s e x a mp l e , a c l a s s i c po s t e r i o r c a na l f l ap wi t h
ve r t i c a l i nc i s i o ns at 1 a nd 6 o ' c l o c k i s us e d ( Fi g. 1 >-
7 A); t h i s i s a g o o d c h o i c e but no t t h e o nl y o ne . T u e
f l a p i s r a i s e d, a nd t h e mi ddl e e a r c a vi t y i s e nt e r , d
b e ne a t h t h e a n n ul us R e me mb e r t hat t h e a nnul , s
pr o v i de s s uppo r t a n d a l l o ws f or ma i n t e n a n c e of t i e
mi ddl e e a r s pa c e . T h e mi ddl e e a r s pa c e i s i ns pe c t e i .
( Fo r i ns pe c t i o n a n d e v a l ua t i o n, s e e T y mp a n o p l a s y
f or At e l e c t a t i c T y mp a n i c Me mb r a n e i n Ch a p t e r I f . )
Fo r t hi s pr o c e dur e ( r e pa i r of a pe r f o r a t i o n a nd r e i n-
f o r c e me nt of t h e me mb r a n e ) i t i s a s s u me d t o t e
no r ma l .
A pi e c e of t h i n S i l a s t i c s h e e t i ng i s pl a c e d f r o m tl"2
s i nus t y mpa ni c a r e a t o t h e e us t a c h i a n t ube . T h s
mi ddl e e a r c a vi t y i s fil l ed wi t h c o mp r e s s e d Ge l f o a n ,
a nd a pi e c e of Ge l f i l m i s pl a c e d o v e r t h e i nc udo s t i -
pe di a l j o i nt ( no t un d e r t h e a nnul us ) , b e t we e n t h t
j o i nt a nd t h e me mb r a n e , i n o r de r t o a vo i d a dh e s i o ns
f r om t h e gr af t t o t h e j o i nt ( Fi g. 1 2 - 7 8 ) .
T h e f as ci a gr af t i s po s i t i o ne d o v e r a n a r e a 3 0 ?
gr e a t e r t h a n t h e e x t e nt o f t h e pe r f o r a t i o n, s i nc e i :
wi l l r e t r a c t b y a b o ut 3 0 % ( Fi g. 1 2 - 7 C) . O n e c o nc e r t :
wi t h gr a f t s i s t h e po s s i bi l i t y of l ack of a de qua t i
c o nt a c t wi t h t h e o v e r l y i ng t y mpa ni c me mb r a n e . B )
t hi s "f a l l i ng i nt o t h e mi ddl e e a r c a v i t y " t h e br i dgi ng
f unc t i on mi gh t b e l os t . Al t h o ug h c o mp r e s s e d Ge l -
f o a m pr o v i de s a de qua t e c o nt a c t ( i f pl a c e d c o r r e c t l y ) ,
a s o und a l t e r na t i v e ( wi t h pr o v e n g o o d r e s ul t s ) i s t h e
us e o f mi c r o c l i ps t o s e c ur e t h e gr a f t a ga i ns t t h e
o v e r l y i ng me mb r a n e . I f t h e t y mp a n i c me mb r a n e i s
we l l de - e pi t h e l i a l i ze d t h e c l i ps wi l l not c a us e a pr o b-
l e m; e v e nt ua l l y t h e v wi l l be e x t r ude d. ( Th i s t e c h -
ni que i s no t de s c r i b e d i n t h i s a t l a s . ) I t i s us e f ul t o
l e a ve a tail ( of t h e f a s c i a ) t o wa r d t h e po s t e r i o r b o n
c a na l t o be r e mo v e d . Th i s s h o ul d be do ne ve r v
c o ns e r v a t i v e l y (if at all po s s i b l e ) i n o r de r t o a v o i d
h a v i ng t h e gr af t r es t o v e r t h e i nc udo s t a pe di a l j o i nt
( wh i c h by no w i s c o v e r e d wi t h Ge l f i l m) . T h e gr af t i s
pl a c e d e mb r a c i ng t h e h a ndl e of t h e ma l l e us . A s ma l l
pi e c e o f f as ci a c a n t h e n be pl a c e d o v e r t h e h a ndl e .
T h e pi e c e of s ki n h a r v e s t e d via t h e L e mpe r t I I i nc i -
s i on i s pl a c e d o v e r t h e f as ci a ( c o v e r i ng t h e pe r f o r a -
t i on) ( Fi g. 1 2 - 7 D ) . T h e e a r i s pa c ke d ( Fi g. 1 2 - 7 E) .
Enda ur a l i nc i s i o ns a r e c l o s e d wi t h t h e a ppr o pr i a t e
s ut ur e s , a nd a dr e s s i ng i s a ppl i e d.
Underlay Graft for
Large Anterior Perforation
A t e mpo r a l f a s c i a gr af t h a s b e e n o b t a i ne d vi a th<
po s t a ur i c ul a r a ppr o a c h . A po s t e r i o r c a na l i nc i s i o n v
ma d e a t t h e b o n y c a r t i l a gi no us j unc t i o n. T h e t y m
pa ni c me mb r a n e i s v i s ua l i ze d, t h e e dg e s o f t h e per -
f or a t i on ar e t r i mme d, t h e unde r s ur f a c e i s s c r a pe d,
T y mp a n o p l a s t y 2 31
FIGURE 12- 7.
r CURE 12
T y mp a n o p l a s t y 2 33
a nd t h e me mb r a n e i s de - e pi t h e l i a l i ze d. (It i s a s s u me d
t hat a c a na l pl a s t y i s no t ne e de d. )
I nc i s i o ns a r e ma d e f or t h e f l ap ( a c l a s s i c po s t e r i o r
c a na l t y mpa no pl a s t y i nc i s i o n, a l t h o ug h o t h e r s c o ul d
h a v e b e e n ma d e a s we l l ) ( Fi g. 1 2 - 8 4 ) . T h e " s wi ng i ng
d o o r s " i mpl y t h e e l e v a t i o n o f s upe r i o r l y a nd i nf er i -
or l y b a s e d s ki n f l a ps . T h e h o r i zo nt a l i nc i s i o n i s ma d e
5 t o 7 mm l at er al t o t h e a nnul us . T h e f l ap i s di vi de d
wi t h a ve r t i c a l i nc i s i o n at 9 o ' c l o c k (it c o ul d a l s o be
a t 11 o ' c l o c k) ; t h i s i nc i s i o n i nv o l v e s b o t h t h e t y mpa ni c
me mb r a n e a nd t h e a nnul us . Th i s r e s ul t s i n t wo f l aps
( o ne s upe r i o r l y a nd o n e i nf e r i or l y b a s e d) , wh i c h a r e
e l e v a t e d a nt e r i o r l y up t o ( a nd b e y o n d i f ne c e s s a r y )
t he ma l l e us s upe r i o r l y , a nd t o 6 o ' c l o c k ( or f ur t he r )
i nf e r i or l y.
T h e mi ddl e e a r c a vi t y i s e nt e r e d a nd e x a mi n e d
(It i s a s s u me d t ha t al l t h a t i s n e e d e d i s pl a c e me nt of
a gr a f t . )
I f o nl y t he a n n ul us i s l eft a nt e r i o r l y , t h e pr o b l e m
o f . gr a f t s uppo r t b e c o me s a n i s s ue . Ab u n d a n t Ge l -
f oa m p a c k i n g s h o ul d be pl a nne d. A g o o d c h o i c e i s
t o de - e pi t h e l i a l i ze t h e a n n ul us a nt e r i o r l y a nd t o ma k e
s ma l l i nc i s i o ns 3 t o 4 mm i n l e ngt h ( or l o nge r i f
n e e d e d ) a nd r a i s e a s ma l l a nt e r i o r f l ap. T h e a nnul us
i s ge nt l y e l e v a t e d a nt e r i o r l y for t h e s a me e x t e nt a s
t he i nc i s i o n ( ma de i n t h e s ki n o f t h e c a na l ) , a nd t he
f as ci a gr af t i s pul l e d b e ne a t h t h e a n n ul us o nt o t he
a nt e r i o r c a na l a nd c o v e r e d wi t h t h e s ma l l a nt e r i o r
f l ap ( Fi g. 1 2 - 8 B , C) . T h i s a v o i ds r e t r a c t i o n o f t h e
gr af t i n s uc h a cr i t i cal a r e a . ( Th e r e s t of t h e gr af t
po s i t i o ni ng i s s i mi l a r t o t ha t i n t h e e nda ur a l a ppr o a c h
de s c r i b e d a b o v e . ) A pi e c e of t hi n Si l a s t i c s h e e t i ng i s
pl a c e d f r om t h e s i nus t y mpa ni t o t h e e us t a c h i a n
t ube . T h e c a vi t y i s fil l ed wi t h c o mp r e s s e d Ge l f o a m;
a pi e c e of Ge l f i l m i s pl a c e d o v e r t h e i nc udo s t a pe di a l
j oi nt . T h e gr af t i s pl a c e d po s t e r i o r l y a s we l l , a nd t he
f l aps a r e r e po s i t i o ne d ( Fi g. 1 2 - 8 D ) . ( No t e t h e di s t i nc t
a dv a nt a g e o f l e a vi ng t h e v a s c ul a r s t r i p unt o uc h e d. )
P a c ki ng i s do ne . I nc i s i o ns a r e c l o s e d wi t h a ppr o pr i a t e
s ut ur e s , a nd a dr e s s i ng i s a ppl i e d.
Allograft for Total Perforation
T h e us e o f a n a l l o ge ne i c t y mpa ni c me mb r a n e
a l l ogr a f t c o ns t i t ut e s o n e mo r e e f f e c t i ve me a n s o f
r e s t o r i ng c o nt i nui t y o f t h e me mb r a n e . Its i ndi c a t i o ns
ar e s i mi l a r t o o t h e r s , but t h i s gr af t i s e s pe c i a l l y us e d
for f a i l ur e s of s t a nda r d t y mpa no pl a s t y ( s uc h a s re-
c ur r e nt pe r f o r a t i o ns o r l a t e r a l i za t i on o f gr a f t s ) , a nd
i n c a s e s i n wh i c h t h e r e i s a h i gh r i s k of f ai l ur e wi t h
s t a nda r d t y mpa no pl a s t y . An a l l ogr a f t i s no t a pa na -
c e a a nd i s no t e a s y t o po s i t i o n a de qua t e l y ; h o we v e r ,
i t a l l o ws t h e us e o f t h e t y mpa ni c me mb r a n e o r
o s s i c l e s , or a t y mpa ni c me mb r a n e wi t h o s s i c l e s . A
do no r me mb r a n e mus t b e s e l e c t e d o f t h e pr o pe r s i ze
a nd s i de t o fit wel l i n t h e r e c i pi e nt .
As s u mi n g e i t h e r a n e nda ur a l or a po s t a ur i c ul a r
a ppr o a c h , e n o u g h b o n e i s r e mo v e d ( by c a na l pl a s t y )
t o c o mpl e t e l y vi s ua l i ze t h e a nnul us ( or t h e s ul c us , i f
t he a n n u l u s i s no t pr e s e nt ) . T h e ma l l e us h a ndl e i s
me t i c ul o us l y c l e a ns e d, a nd t h e t y mpa ni c me mb r a n e
r e mn a n t s a r e de - e pi t h e l i a l i ze d. I f t h e a nnul us i s
a b s e nt , t h e s ul c us i s c a r e f ul l y dr i l l e d i n o r de r t o s e a l
t h e a l l ogr a f t i n g o o d po s i t i o n.
I nc i s i o ns a r e ma d e a t 1 1 , 2, a nd 7 o ' c l o c k a nd
i nc l ude t h e a nnul us , unl e s s t h e a n n ul us i s c o mpl e t e
( Fi g. 1 2 - 9 4 ) . T h e f l aps e x p o s e t h e mi ddl e e a r c a vi t y.
S o me Ge l f o a m i s pl a c e d, a n d a l l ogr a f t i s po s i t i o ne d
first o v e r t h e ma l l e us ( Fi g. 1 2 - 9 B ) . T h e f l a ps a r e t h e n
r e po s i t i o ne d. P a c ki ng i s do ne , t h e i nc i s i o ns a r e
c l o s e d ( Fi g. 1 2 - 9 C) , a nd a dr e s s i ng i s a ppl i e d
An a l l o ge ne i c t y mpa ni c me mb r a n e gr af t h a s c e r -
t ai n dr a wb a c ks . Di f f e r e nt s i de s ( r i gh t or l eft) a nd
s i ze s mus t be a va i l a bl e i n t h e o pe r a t i ng r o o m. I t i s
not e a s y t o po s i t i o n t h e gr af t pr o pe r l y . Al l ogr a f t s
t e nd t o f o r m a dh e s i o ns a nd a r e a s s o c i a t e d wi t h
gr a nul a t i o n t i s s ue i n t h e mi ddl e e a r c a vi t y . ( Si l a s t i c
s h o ul d b e us e d, a s we l l a s Ge l f o a m [ c o ns e r v a t i v e l y ] ) .
I mmu n o l o g i c r e j e c t i o n s o me t i me s o c c ur s . ( Th i s i s
fair l y we l l c o nt r o l l e d, h o we v e r . ) I n a ddi t i o n, t h e r e i s
a po t e nt i a l f or t r a ns mi t t i ng vi r al pa r t i c l e s f r om t h e
do no r t o t h e r e c i pi e nt , s i nc e s o me v i r us e s a r e no t
e a s i l y e l i mi na t e d b y s t e r i l i za t i on pr o c e s s e s . T h e
s o ur c e of t h e al l ogr af t o b v i o us l y i s cr i t i cal
Tympanoplasty-Ossiculoplasty
T h e t i t l e of t hi s s e c t i o n i s c h o s e n f or di da c t i c
pur po s e s . Ho we v e r , t h e r e a de r s h o ul d b e a wa r e t hat
an o s s i c ul o pl a s t y i s pa r t of a t y mpa no pl a s t y . T h e s e
pr o c e dur e s i nv o l v e r e s t o r i ng t h e s o u n d c o nduc t i o n
c a pa bi l i t i e s of t h e o s s i c ul a r c h a i n wi t h or wi t h o ut a
t y mpa ni c me mb r a n e gr af t . T h e e nd r e s ul t s h o ul d b e
c o nt i nui t y i n vi br a t i o n of t h e n e w c h a i n, wi t h a s ol i d
c o nt a c t wi t h
l
h e t y mpa ni c me mb r a n e a nd a mo b i l e
oval wi n d o w me mb r a n e o r pl a t e .
T h e o s s i c ul a r c h a i n o r its c o mp o n e n t s c a n b e
a f f e c t e d by f i xa t i on, di s l o c a t i o n, f r a c t ur e , o r di s s o l u-
t i on ( r e s or pt i j n ) . T h e s e c o ndi t i o ns ma y b e c o nge ni -
tal , o r t h e y c a n be c a us e d by t r a uma , ne o pl a s m, o r
i nf e c t i o n. Th-.> c h o i c e of pr o c e dur e wi l l d e p e n d upo n
t he t y pe o f o s s i c ul a r pr o b l e m, t h e a n a t o mi c e nvi r o n-
me nt , t h e s pa c e a va i l a bl e ( i nt a c t po s t wa l l , c a na l wal l
do wn, a nd s o o n) , a nd t h e s t a t us o f t h e muc o s a
( wh i c h i n t ur n d e p e n d s upo n t h e s t a t us o f t he
2 34 T y mp a n o p l a s t y
FIGURE 12-9.

T y mp a n o p l a s t y 2 35
unde r l y i ng di s e a s e ) . F o r pr a c t i c a l pur po s e s , i t i s
a s s u me d t ha t t h e unde r l y i ng di s e a s e i s unde r c o nt r o l
a nd t h a t t h e mi ddl e e a r s pa c e i s a de qua t e . Al l po s -
s i bl e o s s i c ul a r c h a n g e s a n d e x a mp l e s o f s ur gi c a l
r e pa i r i n s e l e c t e d s i t ua t i o ns wi l l be di s c us s e d, wi t h
t h e unde r s t a ndi ng t h a t t h e r e a r e o t h e r c h o i c e s a va i l -
a bl e .
Isolated Ossicular Lesions
Mal l eus ( Fi g. 1 2 - 1 0 4 )
Th i s i s a n e s s e nt i a l b o n e i n o s s i c ul o pl a s t y r e pa i r .
T h e pr e s e nc e o r a b s e n c e o f t h e h a ndl e o f t h e ma l l e us ,
t o ge t h e r wi t h t h e pr e s e nc e o r a b s e n c e o f a n i nt a c t
a nd mo b i l e s t a pe s , wi l l de t e r mi ne i n gr e a t pa r t t h e
t y pe o f pr o c e dur e t o b e pe r f o r me d.
T h e ma l l e us i s r a r e l y a f f e c t e d a l o ne ; i f i t i s , t h e
pr o b l e m us ua l l y i s a n a nt e r i o r f i xa t i on o f t h e h e a d.
(It ma y a l s o be a t r a uma t i c di s l o c a t i o n. ) If i t i s
a s s o c i a t e d wi t h a mo b i l e s t a pe s , a n a t t i c o t o my i s
do ne wi t h e x po s ur e o f t h e i nc udo ma l l e a l j o i nt ( Fi g
1 2 - 1 0 B , C) ( s e e Ch a p t e r 1 3 ) . T h e f i xa t i on i s ve r i f i e d,
a nd t h e j o i nt i s s e pa r a t e d wi t h a j o i nt kni f e .
P o i nt s t o r e me mb e r : Di s a r t i c ul a t e t h e i nc udo s t a -
pe di a l j o i nt b e f o r e dr i l l i ng i n t h e a t t i c . Th i s wi l l h e l p
t o a v o i d i nne r e a r d a ma g e . Re i nf o r c i ng t h e po s t e r o -
s upe r i o r c a na l qua dr a nt ( a t t i c o t o my s i t e ) be f o r e c l o -
s ur e wi l l di s c o ur a ge r e t r a c t i o n po c ke t s a nd o t h e r
c o mpl i c a t i o ns .
T h e h e a d of t h e ma l l e us i s a mput a t e d wi t h a
ma l l e us ni ppe r ( Fi g. 1 2 - 1 0 D ) . T h e i nc us a l s o i s r e-
mo v e d , s i nc e i t h a s l os t i t s a r t i c ul a t i o n t o t h e h e a d
o f t h e ma l l e us . Re c o ns t r uc t i o n wi l l b e b a s e d t o wa r d
t h e h e a d o f t h e s t a pe s . T h e r e a r e t wo a l t e r na t i ve s :
l a y i ng t h e t y mpa ni c me mb r a n e ( i nt a c t o r gr a f t e d)
o v e r t h e h e a d o f t h e s t a pe s ( c l a s s i c t y pe III t y mpa -
no pl a s t y ) ( Fi g. 1 2 - 1 0 E) , a nd pl a c i ng a gr af t or pr o s -
t h e s i s b e t we e n t h e mo b i l e h a ndl e o f t h e ma l l e us ( t h e
f i xed h e a d h a s b e e n a mput a t e d) a nd t h e h e a d o f t h e
s t a pe s . T h e l a t t e r c o ur s e i s b e t t e r i n t e r ms o f r e-
e s t a b l i s h i ng c o nt i nui t y i n a n a de qua t e mi ddl e e a r
s pa c e . T h i s c a n be d o n e i n a n u mb e r o f wa y s :
1. Us i ng t h e h e a d o f t h e ma l l e us . Ho l di ng t h e
h e a d o f t h e ma l l e us wi t h a n o s s i c l e h o l de r , s h a pe i t
t o fit b e t we e n t h e h e a d o f t h e s t a pe s a nd h a ndl e o f
t h e ma l l e us . Dr i l l a h o l e i n i t t o r e c e i v e t h e h e a d of
t h e s t a pe s . T h e n f l a t t e n i t ( no t c h i t a l i t t l e, ma k i n g a
g r o o v e ) t o fit unde r t h e h a ndl e ( Fi g. 1 2 - 1 0 F ) .
2 . Us i ng t h e i nc us . T h e s h o r t pr o c e s s o f t h e i nc us
i s c l i ppe d. An a c e t a b ul um i s dr i l l e d i n t h e l o ng
pr o c e s s f or f i t t i ng o v e r t h e h e a d o f t h e s t a pe s . Th i s
i s f o l l o we d by dr i l l i ng a gr o o v e o v e r t h e r e ma i ni ng
b o dy f or f i t t i ng unde r t h e ma l l e us h a n d l e ( Fi g. 1 2 -
1 1 4 , B) .
3. Us i ng c or t i c a l b o n e . A gr af t t h a t i s s h a pe d
s i mi l a r t o a s c ul pt ur e d i nc us or ma l l e us h e a d c a n be
dr i l l e d, c r e a t i ng a c o n c a v e h o l e t o fit o v e r t h e h e a d
of t h e s t a pe s a nd a no t c h or a gr o o v e t o f i t unde r
t h e ma l l e us h a ndl e ( Fi g. 1 2 - 1 1 C, D) . (If de s i r e d, a T-
s h a pe d c o r t i c a l b o n e c a n b e us e d. )
4. Us i ng a pa r t i a l o s s i c ul a r r e pl a c e me nt pr o s t h e s i s
( P OR P ) . T h e l a r ge r s ur f a c e a r e a o f a P O R P pr o vi de s
mo r e s t a bi l i t y; h o we v e r , i t mu s t be c o v e r e d wi t h a
t h i n pi e c e o f c a r t i l a ge ( s uc h a s t r a ga l c a r t i l a ge ) t ha t
e x c e e ds t h e e d g e s o f t h e P OR P . Wh e n pl a c e d, i t
mus t pr o v i de a s l i gh t t e ns i o n o v e r t h e t y mpa ni c
me mb r a n e ( Fi g. 1 2 - 1 2 4 ) . T h e c a r t i l a ge i s b e t we e n
t h e P O R P a nd t h e ma l l e us h a ndl e . I f t h e r e i s no
ma l l e us h a ndl e , t h e c a r t i l a ge i s pl a c e d di r e c t l y unde r
t h e t y mp a n i c me mb r a n e o r t y mpa ni c me mb r a n e
gr aft; i n t h e s e c a s e s , a l a r ge pi e c e of c a r t i l a ge i s
pr e f e r r e d. S o me s ur g e o n s e v e n s ut ur e t h e c a r t i l a ge
t o t h e h e a d o f t h e P O R P . I n t h e di s t al po r t i o n o f t h e
P OR P , a n o p e n i n g o r no t c h i s ma d e f or b e t t e r c o nt a c t
wi t h t h e h e a d o f t h e s t a pe s a nd s t a pe di a l t e ndo n. I n
s o me c a s e s a P O R P c a n b e c a r v e d f r om c a r t i l a ge , a nd
t hi s t y pe of gr af t fits qui t e we l l ( Fi g. 1 2 - 1 2 B ) . I t a l s o
a l l o ws t r i mmi ng o f t h e h e a d o f t h e c a r t i l a ge P O R P
t o fit t h e a ng l e d po s i t i o n o f t h e me mb r a n e ( Fi g. 1 2 -
12C) . I n po s i t i o ni ng P O R P s ( a nd T O R P s ) , a b unda nt
Ge l f o a m i s pl a c e d i n t h e mi ddl e e a r c a vi t y i n o r de r
t o pr o v i de s uppo r t a nd ma i nt a i n po s i t i o n af t er r e-
po s i t i o ni ng t h e f l aps a nd t y mpa ni c me mb r a n e . Ce -
r a mi c P O R P s a r e a l s o a va i l a bl e ( Fi g. 1 2 - 1 2 D ) .
Incus ( Fi g. 1 2 - 1 3 4 )
T h e i nc us pr o b l e ms a n d r e pa i r s di s c us s e d h e r e
a s s u me a n i nt a c t ma l l e us h a ndl e a nd s t a pe s . T h e
i nc us i s t h e o s s i c l e mo s t c o mmo n l y a f f e c t e d by e a r
i nf e c t i o ns ( e r o s i o n o f t h e l e nt i c ul a r pr o c e s s ) a nd
t r a uma ( f r a c t ur e - di s l o c a t i o n) . I t ma y a l s o be a b s e nt
( o wi ng t o t r a uma o r pr e v i o us s ur ge r y ) o r f i xed ( us u-
al l y i n a s s o c i a t i o n wi t h t h e ma l l e us h e a d) .
I f e r o s i o n i nv o l v e s a s ma l l po r t i o n of t h e di s t al
e nd o f t h e l e nt i c ul a r pr o c e s s , c o nt i nui t y c a n be r e-
e s t a b l i s h e d b y a ny o f t h e f o l l o wi ng me t h o ds :
1. Us i ng a c or t i c a l b o n e c h i p. A s qua r e of b o ne i s
de l i ne a t e d i n t h e c o r t e x , r e mo v e d, a nd s h a pe d. A
s ma l l a c e t a b ul um i s dr i l l e d f or t h e h e a d o f t h e s t a pe s ,
a nd a g r o o v e f or t h e r e ma i ni ng l o ng pr o c e s s of t h e
i nc us ( Fi g. 1 2 - 1 3 B - E ) .
2. Us i ng a c a r t i l a ge c h i p. A pi e c e of c a r t i l a ge
s h a pe d s i mi l a r l y t o t h e c or t i c a l b o ne c h i p c a n be
us e d.
3. Us i n ^ a pr o s t h e s i s t ha t e mb r a c e s b o t h t h e r e-
ma i ni ng l e i t i c ul a r pr o c e s s a nd t h e h e a d o f t h e s t a pe s .
Text continued on page 241
237 Tympanoplasty
II
lncudoma/leal
JOint
B
D
c
A
E Type III
Graft
Tympanoplasty 236
FIGURE 12-10.
FIGURE 12-11
Ty mpa no pl a s t y
FIGURE 12-13.
T y mp a n o p l a s t y 2 41
[ f t h e r e i s di s l o c a t i o n, t h e i deal pr o c e dur e i s r e a p-
pr o x i ma t i o n a nd r e po s i t i o ni ng us i ng Ge l f o a m o r
" g l u e " ( Fi br i n o r Hi s t o a c r y l ) , o r bo t h . Ho we v e r , t hi s
i s s e l d o m po s s i bl e . I n t r a uma t i c di s l o c a t i o ns , a dh e -
s i o ns a n d f i xa t i ons a r e v e r y c o mmo n .
I f r e a ppr o x i ma t i o n i s no t po s s i b l e , or i nt e r po s i ng
b o n e o r c a r t i l a ge i n l e nt i c ul a r e r o s i o n do e s no t suf -
f i ce, t h e r e a r e a l t e r na t i ve s :
1. I nc us t r a ns po s i t i o n. A s ma l l a t t i c o t o my i s do ne ,
a nd t h e i nc us i s c a r e f ul l y s e pa r a t e d f r om t h e ma l l e us .
I t i s s h a p e d by r e mo v i ng t h e l o ng pr o c e s s , a nd a
no t c h f or t h e s t a pe s h e a d i s ma d e a t t h e e nd o f t he
s h o r t pr o c e s s . T h e a r t i c ul a t i ng s ur f a c e i s e nl a r ge d t o
a c c e pt t h e ma l l e us h a ndl e ( Fi g. 1 2 - 1 4 / 1 ) .
2. Us e o f t h e ma l l e us h e a d. O n c e t h e h e a d i s
r e mo v e d, t h e s i t ua t i o n i s a s de s c r i b e d f or f i xat i on of
t he h e a d o f t h e ma l l e us . T h e s a me pr o c e dur e s a ppl y ,
e x c e pt t ha t i f t h e ma l l e us i s mo b i l e a nd t h e h e a d
i t s e l f i s no t us e d ( a nd a ny o f t h e o t h e r a l t e r na t i ve s
a r e no t pr e f e r r e d) , t h e ma l l e us h e a d i s l eft i n pl a c e
a nd o nl y t h e i nc us i s r e mo v e d .
I n t h e c a s e of a mi s s i ng i nc us , t h e s e c o n d a l t e r -
na t i ve r e ma i ns va l i d. I n al l of t h e s e pr o c e dur e s ,
a l l o ge ne i c ( a l l ogr a f t ) o s s i c l e s a nd c a r t i l a ge a r e a l s o a
go o d a l t e r na t i v e
An o t h e r me t h o d i s t o us e a n i nt e r po s i t i o n pr o s -
t h e s i s ma d e of h y dr o x y a pa t i t e . A po c ke t i s c r e a t e d
b e t we e n t h e ma l l e us a nd t h e o v e r l y i ng me mb r a n e .
T h e l a r ge e nd o f t h e pr o s t h e s i s i s pl a c e d o v e r t he
h e a d o f t h e s t a pe s a nd t h e di s t al ( t h i n) e nd i n t hi s
ne wl y c r e a t e d po c ke t ( Fi g. 1 2 - 1 4 B ) . T h e a dv a nt a g e
i s t h a t s t a bi l i t y i s pr o v i de d by ut i l i zi ng b o t h t h e
t y mpa ni c me mb r a n e a nd ma l l e us h a ndl e , wi t h no
c o nne c t i o n t o t h e b o n y a nnul us o r f aci al r i dge . Th i s
i s a c l e v e r pr o s t h e s i s ( wh i c h stil l mus t s t a nd t h e t es t
o f t i me , h o we v e r ) . I t mus t be me n t i o n e d , h o we v e r ,
t ha t dr i l l i ng i n i t i s no t s o s i mpl e a s s ug g e s t e d
P a t i e nc e , c a r e f ul ne s s , a nd c o pi o us i r r i ga t i on a r e r e c -
o mme n d e d . An a ddi t i o na l pr o s t h e s i s o f t h i s s a me
ma t e r i a l ( t h e We h r s i nc us pr o s t h e s i s ) ful fil l s ve r y
ni c e l y t h e f unc t i o n of a s c ul pt ur e d i nc us b e t we e n t h e
ma l l e us a nd s t a pe s h e a d wi t h o ut t h e dr i l l i ng a nd
s c ul pt ur i ng o f t h e i nc us . Th i s t oo mus t b e e v a l ua t e d
o v e r t i me .
Stapes
Fi xa t i o n o f t h e s t a pe s by o t o s c l e r o s i s i s de a l t wi t h
i n Ch a p t e r 13. Fi xa t i o n r e l a t e d t o i nf l a mma t i o n (fi-
b r o s i s ) or t y mpa no s c l e r o s i s i s r a r e i n a n i s o l a t e d f or m
( t h a t i s , no t a f f e c t i ng o t h e r o s s i c l e s a t t h e s a me t i me ) .
I n t h e s e e x c e pt i o na l c a s e s , a s t a p e d e c t o my wi l l suf -
fice a nd t h e r e s ul t s s h o ul d be a s g o o d a s i n o t o s c l e -
r os i s . Ho we v e r , i t i s e s s e nt i a l t o do t hi s s t a pe de c t o my
i n a " dr y e a r " a nd as a s i ngl e pr o c e dur e . It s h o ul d
not be pe r f o r me d i n c o nj unc t i o n wi t h a t y mpa no -
pl a s t y b e c a u s e o f a h i gh r i s k o f s e ns o r y h e a r i ng l o s s .
If a t y mpa no pl a s t y i s pe r f o r me d, t h e s t a pe de c t o my
i s de l a y e d. Ca r e f ul s t a gi ng i s c r uc i a l .
Fr a c t ur e s of t h e c r ur a a r e t r e a t e d wi t h a pi s t o n
pr o s t h e s i s f r o m t h e i nc us t o t h e ova l wi n d o w, unl e s s
t he f r a c t ur e i s t h e r a r e o n e t h a t a l l o ws a c r ur o t o my .
Aga i n, t h e s e pr o c e dur e s a r e d o n e i n a " dr y e a r . " I n
c a s e s of f r a c t ur e d c r ur a a nd f o o t pl a t e , i t i s s a f e r t o
r e mo v e t h e f o o t pl a t e a n d us e c o nne c t i v e t i s s ue t o
s e a l t h e wi n d o w. ( A wi r e c o nne c t i v e t i s s ue pr o s t h e s i s
i s pr e f e r r e d b ut i t i s no t e s s e nt i a l . ) An a l t e r na t i v e i n
f r a c t ur e d c r ur a a nd i nt a c t mo b i l e f o o t pl a t e i s t h e us e
o f a n i nv e r t e d a l l ogr a f t s t a pe s ( Fi g. 1 2 - 1 4 C) .
Combi ned Ossicul ar Probl ems
Re pa i r s b e c o me mo r e t r o ub l e s o me i f t h e ma l l e us
h a ndl e o r s t a pe s ( or b o t h ) a r e a b s e nt . Th i s me a n s
t hat t h e pr o s t h e s i s mus t b e s uppo r t e d b y t h e gr a f t e d
t y mpa ni c me mb r a n e , wh i c h c a r r i e s a h i gh e r r i s k o f
f ai l ur e, or a l o nge r pr o s t h e s i s mus t be us e d f r om t h e
t y mpa ni c me mb r a n e t o t h e o va l wi n d o w.
Fi xa t i on o f t h e h e a d o f t h e ma l l e us a s s o c i a t e d wi t h
a f i xed s t a pe s f o o t pl a t e h a s b e e n s h o wn t o be r e-
pa i r e d wi t h a ma l l e us - t o - o v a l - wi ndo w wi r e c o n n e c -
tive t i s s ue pr o s t h e s i s . Wh i l e t h i s i s a g o o d a l t e r na t i ve ,
i t h a s t h e dr a wb a c ks o f l a t e r a l i za t i o n a nd l o s s o f
a de qua t e c o nduc t i v i t y . I t mus t be r e me mb e r e d t hat
wh e n e v e r t h e s t a pe s f o o t pl a t e i s r e mo v e d , a f i s t ul a
of t he o va l wi n d o w i s a po t e nt i a l c o mpl i c a t i o n. Re -
ga r dl e s s o f t h e gr af t o r pr o s t h e s i s , a n a de qua t e s eal
i s e s s e nt i a l . Al t e r na t i v e s i nc l ude t h e us e of a T O R P ,
a T O R P - s h a p e d c o r t i c a l b o n e o s s i c l e , c a r t i l a ge , or
c e r a mi c pr o s t h e s i s , or a s c ul pt ur e d o s s i c l e ( a ut o l o -
go us o r a l l o ge ne i c ) .
I n c a s e s o f f i xat i on o f t h e o s s i c ul a r c h a i n by t y m-
pa no s c l e r o s i s , t h e first s t a ge i mpl i e s mo bi l i za t i o n,
c o mpl e t i o n o f t h e ma l l e us , di s a r t i c ul a t i o n o f t he
i nc us , a nd SJ o n. Th i s pr e pa r e s f or a s e c o n d pr o c e -
dur e i n wh i c h t h e s t a p e d e c t o my i s d o n e . S ur gi c a l
r e pa i r i nv o l v e s t h e a l t e r na t i v e s de s c r i b e d b e l o w.
Wh e n b o t h t h e ma l l e us a nd i nc us a r e a b s e nt
( us ua l l y s e e n i n c h r o ni c ot i t i s me di a c a s e s , a nd not
u n c o mmo n l y i n t y mp a n o ma s t o i d e c t o my pr o c e -
dur e s ) , o r wh e n b o t h o s s i c l e s a r e a s i ngl e , c o nge ni t a l ,
no nf unc t i o na l " ma s s , " t h e a l t e r na t i ve s a r e a c l a s s i c
t y pe III t y mpa no pl a s t y or us e of a s h o r t pr o s t h e s i s
or gr af t ( de s c r i b e d a b o v e ) , i f t h e s t a pe s i s i nt a c t a nd
mo b i l e . I f t h e s t a pe s i s f i xed or d a ma g e d , a l o ng
pr o s t h e s i s ( t y mpa ni c me mb r a n e t o f o o t pl a t e o r ova l
wi n d o w gr a f t ) i s ne c e s s a r y
T y mp a n o p l a s t y 2 43
I f t h e ma l l e us i s a b s e nt a nd t h e r e i s a n i nt a c t a nd
mo b i l e s t a pe s , a s h o r t pr o s t h e s i s i s us e d. Ho we v e r ,
a l o ng pr o s t h e s i s i s i ndi c a t e d i f t h e s t a pe s i s d a ma g e d
( Fi g. 1 2 - 1 4 E) .
I n c a s e s o f t y mp a n o ma s t o i d e c t o my , t h e c o nc e pt
o f s pa c e b e c o me s r e l e v a nt i n t e r ms o f r e c o ns t r uc t i o n
At t h i s po i nt a nd wi t h t h i s t y pe o f di s e a s e , a n i nt a c t -
b r i dge t y mp a n o ma s t o i d e c t o my ma k e s g o o d s e ns e (if
n e e d e d , o f c o ur s e ; i f po s s i b l e , a n i nt a c t - wa l l pr o c e -
dur e i s pr e f e r r e d) .
As me n t i o n e d e a r l i e r , a cr i t i cal f a c t or i s t h e pr e s -
e nc e o r a b s e n c e o f t h e ma l l e us h a ndl e . An e qua l l y
i mpo r t a nt f a c t or ( s o me t i me s o v e r l o o ke d) i s t h e pr e s -
e nc e o r a b s e n c e o f a mo b i l e f o o t pl a t e . Fo r pr a c t i c a l
pur po s e s , t h e us e o f a T O R P wi l l be de s c r i b e d,
f o l l o we d b y o t h e r a l t e r na t i ve s .
Placement of a TORP
T wo po i nt s o f c o nt a c t a r e c r uc i a l . T h e us ua l t e n-
de h c y . i s . t o t h i nk i n t e r ms o f e x t r us i o n a n d f or ge t t h e
di s t al e nd o f t h e T O R P ( o ve r t h e f o o t pl a t e o r ova l
wi n d o w gr a f t ) .
T h e T O R P i s c ut t o t h e ne c e s s a r y l e ngt h . Th i s ma y
be 3 . 5 mm f or a n o p e n c a vi t y , 4 mm i f t h e ma l l e us
h a ndl e i s pr e s e nt , or 5 mm i f i t i s a b s e nt .
A t h i n b ut l a r ge pi e c e of c a r t i l a ge i s pl a c e d o v e r
t he T O R P ( b e ne a t h t h e ma l l e us o r t y mpa ni c me m-
b r a ne gr a f t ) t o pr o v i de pr o t e c t i o n f r o m e x t r us i o n
( s o me s u r g e o n s s ut ur e i t t o t h e T O R P ) . I f t h e r e i s a
f o o t pl a t e o r me mb r a n e , t h e T O R P i s pl a c e d o v e r i t
a nd i s s uppo r t e d wi t h a b unda nt Ge l f o a m t o s e c ur e
i t i n po s i t i o n. A T O R P wi t h a pe g c a n be us e d t o
pr o v i de mo r e s t a bi l i t y a t t h e f o o t pl a t e a nd pr e v e nt
s l i ppi ng ( Fi g. 1 2 - 1 5 A) . O n c e t h e T O R P i s pl a c e d, i t
s h o ul d i mpa r t s o me t e ns i o n t o t h e t y mpa ni c me m-
b r a ne . A T O R P - s h a p e d pi e c e o f c a r t i l a ge o r c or t i c a l
b o n e c a n be us e d, a s we l l . A s ma l l pi e c e o f Si l a s t i c
c a n be pl a c e d, s ur r o undi ng t h e pr o s t h e s i s a t t h e ova l
wi n d o w a r e a , i n o r de r t o pr e v e nt a d h e s i o n s ( Fi g. 1 2 -
15C) . A c e r a mi c T O R P c a n a l s o b e us e d ( Fi g. 1 2 -
1 5D) , a s we l l a s a s c ul pt ur e d i nc us . T h e l a t t e r s h o ul d
be f l a t t e ne d t o wa r d t h e t y mp a n i c me mb r a n e i n o r de r
t o pr o v i de a s mo o t h a nd wi de c o nt a c t . I f t h e ma l l e us
h a ndl e i s pr e s e nt , dr i l l i ng a g r o o v e i n t h e T O R P
pr o v i de s b e t t e r s t a bi l i t y. Wh e n e v e r a l o ng pr o s t h e s i s
( T O R P t y pe ) i s pl a c e d o v e r a n o va l wi n d o w wi t h o ut
a f o o t pl a t e , t h e r e i s a po s s i bi l i t y of a f i s t ul a a nd go o d
s e a l i s ne e de d. If t h e r e i s a po t e nt i a l f or r e t r a c t i o n
(for e x a mp l e , e us t a c h i a n t ub e dy s f unc t i o n) , t h e s e
pr o s t h e s e s ma y l e a d t o f i s t ul i za t i on b y s l i di ng i nt o
t h e o va l wi n d o w.
Pertinent Histopathology
F I G UR ES 1 2 - 1 6 T O 1 2 - 1 8
Ch r o n i c ot i t i s me di a wi t h pe r f o r a t i o n o f t h e t y m-
pa ni c me mb r a n e . T h e l o we r ma gni f i c a t i o n ( Fi g. 1 2 -
16) s h o ws t h e t h r e e l a y e r s o f t h e t y mpa ni c me m-
br a ne ; ( 1) t h e o ut e r e pi t h e l i um ( s t r at i f i ed s q u a mo u s
e pi t h e l i um) , c o nt i nuo us wi t h t h a t o f t h e e x t e r na l e a r
c a na l ; ( 2) t h e mi ddl e e a r c o nne c t i v e t i s s ue l a ye r ,
c o nt i nuo us wi t h bo t h t h e c o nne c t i v e t i s s ue l a y e r o f
t h e e x t e r na l e a r c a na l a nd mi ddl e e a r ; a n d ( 3) t he
i nne r muc o s a l l a y e r , c o nt i nuo us wi t h t h a t o f t he
mi ddl e e a r . T h e h i gh e r ma gni f i c a t i o ns ( Fi gs , 1 2 - 1 7 ,
1 2 - 1 8 ) c l e a r l y s h o w t h e i ng r o wt h o f o ut e r s t r at i f i ed
s q u a mo u s e pi t h e l i um (arrows). Th i s e pi t h e l i um i s
r e mo v e d b e f o r e pl a c e me nt o f a c o nne c t i v e t i s s ue
gr af t ; o t h e r wi s e t h e r e wi l l be no mi gr a t i o n o f e pi t h e -
lial c e l l s o v e r t h e gr af t . T h e pur po s e of t h e gr af t i s
t o " r e p l a c e " t h e l os t c o nne c t i v e t i s s ue a n d t o s e r ve
a s a b r i dge f or mi gr a t i o n of e pi t h e l i a l c e l l s t o c l o s e
t he g a p ( pe r f o r a t i o n) . T h e s e p h o t o mi c r o g r a p h s i l l us -
t r at e t h e c o nc e pt s o f pe r f o r a t i o n a nd gr a f t i ng; t h e y
a r e no t me a n t t o i mpl y or t o s ugge s t gr a f t i ng a
pe r f o r a t i o n dur i ng a n a c ut e e pi s o de o f ot i t i s me di a ,
e v e n i f s u p e r i mp o s e d o v e r a c h r o ni c pr o c e s s .
245 Tympanoplasty
,"""
External ear canal
FIGURE 12-17.
. ~
.) EXlerna! ear canal
244 Tympnnoplasty
2 46 T y mp a n o p l a s t y
FIGURE 12-1K
CHAPTER 13
Surgery for
Stapes Fixation
S t a pe s pr o c e dur e s a i m t o r e - e s t a bl i s h s o u n d t r a ns -
mi s s i o n t h r o ugh a s t i f f e ne d o s s i c ul a r c h a i n, s e c o n-
da r y to' f i xa t i on o f t h e s t a pe s . T h e s e pr o c e dur e s
i nv o l v e pa r t i a l o r t ot a l r e mo v a l o f t h i s o s s i c l e a nd
r e pl a c e me nt wi t h mo b i l e po r t i o ns of i t or wi t h a
pr o s t h e s i s .
T wo s ur gi c a l pr o c e dur e s t ha t h a v e b e e n us e d
s uc c e s s f ul l y f or s t a pe s f i xa t i o n wi l l no t be di s c us s e d
at l e ngt h h e r e . Al t h o u g h a de t a i l e d de s c r i pt i o n i s
b e y o n d t h e s c o pe o f t h i s a t l a s , t h e r e a de r s h o ul d b e
a wa r e o f t h e m. T h e y a r e ( 1) f e ne s t r a t i o n o f t h e l at er al
s e mi c i r c ul a r c a na l , a nd ( 2) s o no i nv e r s i o n. F e ne s t r a -
t i on o f t h e l at er al s e mi c i r c ul a r c a na l a l l o ws vi br a t i o ns
t o r e a c h t h e ha i r c e l l s t h r o ugh t h e s c a l a vc s t i bul i ,
b y pa s s i ng t h e o s s i c ul a r c h a i n, wi t h a r e s ul t a nt mi l d
a i r - b o ne g a p o f 25 t o 30 dF3. Al t h o ug h t h i s pr o c e dur e
h a s b e e n r e pl a c e d by s t a pe de c t o my , i t s h o ul d be
ke pt i n mi nd. I t c a n be of us e i n s o me unus ua l c a s e s
o f o t o s c l e r o s i s , a s a n i nt e r va l o pe r a t i o n i n s o me f o r ms
o f t y mpa no pl a s t y , a nd c o ul d e v e nt ua l l y r e - e me r ge
as a s ur gi c a l t e c h ni que f or de l i ve r y of dr ugs t o t he
i nne r e a r . S o no i nv e r s i o n ( t e c h ni que o f Ga r c i a - I b a ne z )
de l i ve r s vi br a t o r y s t i mul a t i o n t h r o ugh t h e r o und
wi n d o w me mb r a n e by ut i l i zi ng a pr o s t h e s i s f r om t h e
i nc us o r ma l l e us t o t h e r o und wi n d o w. T h e no r ma l
me c h a n i s m o f s o u n d t r a ns mi s s i o n vi a t h e o s s i c ul a r
c h a i n t o t h e ova l wi n d o w i s s uc c e s s f ul l y " i nv e r t e d. "
T h e b a s i c h e a d po s i t i o n wi t h s l i gh t h y pe r t e ns i o n
a nd t h e t r a ns c a na l a ppr o a c h h a v e a l r e a dy b e e n de -
s c r i be d; t h e di s c us s i o n wi l l f o c us o n pr o c e dur e s af t er
t he a n n ul us h a s b e e n e l e v a t e d.
S t a pe s pr o c e dur e s ge ne r a l l y a r e d o n e unde r l ocal
a ne s t h e s i a wi t h s e da t i o n. Ge ne r a l a ne s t h e s i a a l s o
c a n be us e d; h o we v e r , i t h a s t h e di s a dv a nt a g e o f
pr e v e nt i ng t h e s ur ge o n f r om mo ni t o r i ng ve s t i bul a r
s y mp t o ms o r h e a r i ng ga i ns i n t h e o pe r a t i ng r o o m.
S o me s u r g e o n s pr e f e r a s ma l l e nda ur a l a ppr o a c h ,
s i nc e i t pr o v i de s g o o d e x po s ur e a nd a l l o ws b i ma nua l
s ur ge r y wi t h o ut t h e ne e d f or s pe c ul um h o l de r s ;
h o we v e r , s p e c u l u m h o l de r s a r e us e d by a ma j or i t y
of s ur g e o ns . Tjhe a ut h o r s pr e f e r a t r a ns c a na l ap-
pr o a c h , us i ng a n e a r s p e c ul um wi t h o ut a h o l de r . A
we l l - f i t t e d e a r s p e c ul um h o l ds i n pl a c e qui t e we l l . I t
i s no t h a r d t o s t a bi l i ze t h e s p e c ul um wi t h t h e l eft
h a nd ( f or a r i gh t - h a nde d s ur g e o n ) , wh i l e us i ng a n
i ns r ume nt ( s uc h a s a s uc t i o n t i p) a t t h e s a me t i me .
T h e pr o c e dur e c a n be s t a r t e d wi t h a s ma l l e r s pe c -
ul um; o n c e t h e i nc i s i o ns h a v e b e e n ma d e , a t i gh t l y
f i t t i ng o n e i s us e d.
S ma l l e x o s t o s e s o f t h e c a na l (if a ny ) a r e r e mo v e d.
(If t h e y a r e l a r ge or i f a c a na l pl a s t y i s ne c e s s a r y , t hi s
s h o ul d be d o n e a s a s e pa r a t e pr o c e dur e a nd t he
s t a pe de c t o my de l a y e d unt i l c o mpl e t e h e a l i ng h a s
b e e n a c h i e v e d, wh i c h c o ul d be a ma t t e r o f mo nt h s . )
I t s h o ul d be r e me mb e r e d t h a t e nt r a nc e t o t h e mi ddl e
e a r mus t be ma d e i n a dr y f i el d a nd b e n e a t h t he
a nnul us . F r o m t h i s po i nt o n, t h e mi c r o s c o pe i s us e d
a t a ma gni f i c a t i o n of a t l e a s t 10 x. I n ge ne r a l t e r ms
t h e r e a r e t h r e e b a s i c t y pe s o f s t a pe de c t o my pa r t i a l ,
t ot al , a nd pi s t o n. T h e pr o c e dur e h e r e wi l l be a
ge ne r a l a ppr o a c h , a nd t h e di f f e r e nt t y pe s wi l l be
de s c r i b e d o n t h e ba s i s o f t h e f i ndi ngs a nd t h e i r
i ndi c a t i o ns
On c e t h e a n n ul us i s e l e v a t e d, t h e first o b j e c t i v e i s
t o o bt a i n a de qua t e e x po s ur e a nd t h e n t o e x pl o r e t he
e a r . Wo r k o n t h e s t a pe s i s t h e f i na l s t e p, a n d i s o nl y
b e g un af t er al l o t h e r wo r k i s c o mpl e t e d. A us e f ul
r ul e o f t h u mb f or e x po s ur e o f t h e o va l wi n d o w i s t o
a c h i e v e c l e a r vi s ua l i za t i o n o f t h e py r a mi da l e mi n e n c e
a nd t h e s upe r i o r a s pe c t o f t h e f aci al ne r v e . Mo s t o f
t h e t i me , t h i s r e qui r e s r e mo v a l o f b o n e f r om t he
po s t e r i o r c a na l ; i n do i ng s o , t h e c h o r da t y mpa ni
S ur ge r y f or S t a pe s Fi xa t i o n 2 49
mus t be f r e e d. Us ua l l y a f i ne ne e dl e c a n be us e d t o
mo b i l i ze t h e c h o r da a nt e r i o r l y t o wa r d t h e i nc us ( Fi g.
1 3 - 1 / 1 ' ) . I f t h e c h o r da wi l l be s t r e t c h e d by t h i s
ma n e u v e r , i t i s b e t t e r t o s e c t i o n i t s h a r pl y wi t h a
kni f e or a Be l l uc c i s c i s s o r s ( Fi g. 1 3 - 1 / 1 ) .
Bo n e o f t h e po s t e r i o r c a na l c a n b e dr i l l e d o r
c ur e t t e d. T h e a ut h o r s pr e f e r t o c ur e t i t wi t h l a r ge
s t a pe s c ur e t s i n s t r o ke s a wa y f r o m t h e o s s i c l e s
( a v o i di ng l ux a t i o n o f t h e o s s i c l e s ) . Me t i c ul o us r e-
mo v a l o f b o n e c h i ps s h o ul d b e d o n e ( Fi g. 1 3 - 1 B ) .
O n c e vi s ua l i za t i o n h a s b e e n a c h i e v e d, al l a na t o mi c
l a n d ma r k s a r e i ns pe c t e d ( Fi g. 1 3 - 1 Q .
T h e pr e s e nc e o f a n o p e n r o und wi n d o w i s i mpo r -
t a nt . To t a l o bl i t e r a t i o n wi l l l e a d t o a po o r e r r e s ul t .
Dr i l l i ng a r o und wi n d o w a l s o l e a ds t o po o r r e s ul t s
a nd c o mpl i c a t i o ns a n d i s no t r e c o mme n d e d . A ve r y
s ma l l o p e n i n g (70/ s ur gi c a l l y i nduc e d) i n t h e wi n d o w
s h o ul d s uf f i c e f or a s a t i s f a c t o r y o u t c o me ; t h i s s h o ul d
b e ke pt i n mi nd. Ho we v e r , i n s o me pa t i e nt s wi t h
o bl i t e r a t e d r o und wi n d o ws s o me ga i n i n h e a r i ng c a n
b e o b t a i ne d; s i nc e s uc h a n i mp r o v e me n t mi gh t ma k e
a s i gni f i c a nt di f f e r e nc e i n t h e i r l i ve s , a s t a p e d e c t o my
s h o ul d b e a t t e mpt e d.
T h e o s s i c ul a r c h a i n i s t h e n pa l pa t e d ( us i ng a n
a ngl e d h o o k o r Ho u g h h o e ) i n o r de r t o l o c a t e po i nt s
o f o s s i c ul a r f i xa t i on ( Fi g. 1 3 - 1 D , E) . S pe c i a l a t t e nt i o n
i s pa i d t o c a s e s o f uni l a t e r a l h e a r i ng l o s s , i n wh i c h
no no t o s c l e r o t i c f i x a t i o ns a r e mo r e f r e que nt . Fi xa t i o n
o f t h e ma l l e us mo s t of t e n i s c o nge ni t a l , a nd t h e
f i xa t i on i s a t t h e h e a d. T h i s f i ndi ng r e qui r e s a n
a t t i c o t o my ( pr e v i o us l y de s c r i b e d) a n d e x po s ur e o f
t h e h e a d o f t h e ma l l e us ( Fi g. 1 3 - 2 / 1 ) . T h e a ut h o r s
pr e f e r t o us e c ur e t s , but i f a dr i l l i s us e d, t h e i nc us
s h o ul d b e s e pa r a t e d f r o m t h e h e a d o f t h e s t a pe s wi t h
a j o i nt kni f e i n o r de r t o a v o i d a c o us t i c t r a uma .
At t a c h me n t s c a n s o me t i me s b e r e l e a s e d, a nd s ma l l
pi e c e s o f S i l a s t i c c a n be pl a c e d t o a v o i d f i xat i on ( Fi g.
1 3 - 2 6 ) ; h o we v e r , unl e s s t h e a t t a c h me n t s a r e mi ni -
ma l , t h i s i s us ua l l y f o l l o we d by r e f i xa t i on. A s ol i d
f i xa t i on r e qui r e s r e mo v a l o f t h e h e a d o f t h e ma l l e us
wi t h ma l l e us ni ppe r s ( Fi g. 1 3 - 2 C) a nd pl a c e me nt o f
a ma l l e us t o ova l wi n d o w pr o s t h e s i s , a b o n e s t r ut ,
or a t ot al o s s i c ul a r r e pl a c e me nt pr o s t h e s i s ( T OR P )
( Fi g. 1 3 - 2 D - F ) . ( S e e a l s o Ch a pt e r 14 f or a l t e r na t i ve
pr o c e dur e s ut i l i zi ng a l a s e r . )
Un d e r 10 X or 16 x ma gni f i c a t i o n, t h e ova l
wi n d o w a nd s t a pe s a r e i ns pe c t e d ( Fi g. 1 3 - 3 ) . I s t h e r e
a no r ma l - s i z e d o va l wi n d o w, a p r o mo n t o r y o ve r -
h a ng, or a de h i s c e nt f aci al ne r v e ? I s t h e f aci al ne r v e
o v e r t h e f o o t pl a t e ? I s t h e r e a pe r s i s t e nt s t a pe di a l
a r t e r y ? I s t h e s t a pe s f i xed a nt e r i o r l y o r po s t e r i o r l y ?
I s t h e f o o t pl a t e o f no r ma l s i ze ( o n a v e r a ge , 1. 4 mm
wi de a n d 3 . 0 mm l o ng) ? I s pa r t , h a l f , o r al l o f t h e
f o o t pl a t e i nv o l v e d? I s t h e r e o bl i t e r a t i o n o f t h e f oot -
pl a t e a nd wi n d o w b y o t o s c l e r o t i c f oci ?
On t h e b a s i s o f t h e s e o b s e r v a t i o ns a n d t h e pr ef -
e r e nc e a n d e x pe r i e nc e o f t h e s ur ge o n, t h e s pe c i f i c
s ur gi c a l pr o c e dur e i s s e l e c t e d. Re ga r dl e s s o f t h e
pr o c e dur e , t h e unde r l y i ng i de a i s t ha t al l or pa r t of
t h e f o o t pl a t e i s t o be r e mo v e d , a nd a me mb r a n e
( pr e f e r a bl y c o l l a g e no us ) u s e d i n its pl a c e for a s e a l .
If a pr o s t h e s i s wi l l be e mp l o y e d , a f i r m a nd l a s t i ng
c o nt a c t mu s t b e e s t a b l i s h e d wi t h t h e l o ng pr o c e s s o f
t h e i nc us ( or t h e ma l l e us h a ndl e ) .
Total Stapedectomy
with Prosthesis
T h e c l a s s i c t ot al s t a p e d e c t o my i s us e d h e r e a s t h e
pr i ma r y pr o c e dur e t o de s c r i b e ge ne r a l pr i nc i pl e s a nd
p r o b l e ms e n c o un t e r e d dur i ng s ur ge r y . T h e de s c r i p-
t i on a s s u me s t h a t t h e r e i s no no b l i t e r a t i v e f i xa t i on o f
t h e s t a pe s , t h e r e s t o f t h e o s s i c l e s a r e mo b i l e , t h e
r o und wi n d o w i s pa t e nt , a n d t h e o va l wi n d o w i s o f
no r ma ! s i ze . T h e di s t a nc e b e t we e n t h e i nc us a nd t h e
f o o t pl a t e i s me a s u r e d . T h e a v e r a g e me a s u r e me n t
f r om t h e h e a d o f t h e s t a pe s t o t h e f o o t pl a t e i s 3 . 2 9
mm 0. 1 5 mm, t o wh i c h i s a dde d 1 mm o f t h e
l e nt i c ul a r pr o c e s s . T h e a v e r a g e l e ngt h o f a pr o s t h e s i s
i s 4 . 0 mm i n wo me n a n d 4 . 2 5 t o 4 . 5 0 mm i n me n. I f
a wi r e c o nne c t i v e t i s s ue pr o s t h e s i s i s t o be us e d, i t
s h o ul d b e ma d e a t t h i s t i me . Co n n e c t i v e t i s s ue
s h o ul d be h a r v e s t e d a t t h i s po i nt a s we l l .
Harvesting a Graft
On c e t h e s t a pe s h a s b e e n r e mo v e d, t h e v e s t i b ul e
i s e x p o s e d a nd a n e w me mb r a n e i s n e e d e d t o s e a l
t h e o pe ni ng . Co n n e c t i v e t i s s ue , s pe c i f i c a l l y c o l l a ge n,
a l l o ws t h e f o r ma t i o n of a s t a bl e s e a l t h a t b e c o me s
par t o f t h e wi n d o w. Wh i l e Ge l f o a m s t i mul a t e s t i s s ue
gr o wt h a n d i s us e d s a t i s f a c t or i l y b y ma n y s ur ge o ns ,
t h e s e me mb . a n e s t e nd t o be t h i n a nd c a r r y a h i gh e r
r i s k o f f i s t ul a f o r ma t i o n a n d pe r i l y mph l e a ka ge . Dif-
f e r e nt s o ur c e s a r e us e d, s uc h a s fat a nd c o nne c t i v e
t i s s ue f r o m t h e e a r l o b e o r po s t a ur i c ul a r a r e a , t r agal
pe r i c h o ndr i um, or a v e i n. Ti s s ue f r om t h e e a r l o b e
a nd po s t a ur i c ul a r a r e a i s us e d f or wi r e c o nne c t i v e
t i s s ue pr o s t h e s e s , a nd f r o m pe r i c h o ndr i um o r ve i n
a s s e a l i ng me mb r a n e s wi t h s i mpl e wi r e s o r pi s t o ns .
T y pe o f pr o s t h e s i s , e a s e o f h a ndl i ng, a nd i ndi vi dua l
pr e f e r e nc e s wi l l de t e r mi ne s uc h c h o i c e s
A s ma l l i nc i s i o n s uf f i c e s f or h a r v e s t i ng t i s s ue f r o m
t h e e a r l o b e o r po s t a ur i c ul a r a r e a ( Fi g. 13-4A, 6 ) . T h e
i nc i s i o n i s c l o s e d wi t h o n e o r t wo a ppr o pr i a t e s ut ur e s
2 50 Su r g e r y for St ape s Fi xat i on
FIGURE 13-2.
Sur g e r y f or St apes Fi xat i o n 2 51
FIGURE 13-3.
Sur g er y f or St apes Fi xat i on 253
and t he t i s s ue i s left i n s al i ne s ol ut i on. Tr ag al per i -
c ho nd r i u m i s o bt ai ned vi a a s mal l i nci s i on i n t he
u nd e r s u r f ac e o f t he t r ag us , expo s i ng t he per i cho n-
d r i u m, whi c h can be peel ed off t he under l yi ng car -
t i l age ( Fi g. 1 3 - 4 C) . Met i cul o us he mo s t as i s i s d o ne ,
t he i nci si on i s cl os ed wi t h t wo or t hr ee appr o pr i at e
s ut ur es , and t he pe r i c ho nd r i u m i s gent l y pr e s s e d
and r i ns ed i n s al i ne. All i ns t r u me nt s and mat er i al s
us ed i n t hi s ar ea s ho ul d be r i ns ed i n o r d e r t o r e mo v e
any par t i cl es f r om t hei r s ur f aces .
Vei n can be har ve s t e d f r o m t he d o r s u m o f t he
ha nd by a s mal l i nci s i on. Bo t h e nd s ar e car ef ul l y
t i ed; t he mi ds ect i o n of t he vei n ( si ze as ne e d e d ) i s
r e mo v e d and spl i t o pe n, t he endo t hel i al l ayer i s
r e mo v e d , and t he vei n i s pr es s ed and r i ns ed i n s al i ne
( Fi g. 1 3 - 4 D) . I n g ener al , t he advent i t i al l ayer i s
pl aced f aci ng t he ves t i bul e. Wi t h pe r i c ho nd r i u m, t he
s i de i n di r ect c o nt ac t wi t h t he car t i l age i s pl aced
f aci ng t he mi ddl e ear ; o t he r wi s e s mal l car t i l age r e m-
nant s ma y fall i nt o t he ves t i bul e, pot ent i al l y caus i ng
co mpl i cat i o ns .
Making the Prosthesis
Ma n y s at i s f act or y pr o s t he s e s ar e c o mme r c i al l y
avai l abl e. Exc e pt for po l yet hyl ene s t r ut s and wi r e
Ce l f o am pr o s t he s e s ( whi ch t end t o have a hi gher
i nci dence of f i st ul ae) and Pl as t i por e pi s t ons ( whi ch
t end t o c au s e l ocal r eact i o ns ) , t he vas t maj o r i t y of
pr o s t he s e s ar e s at i s f act or y i f pr o per l y us ed. Thei r
us e will d e pe nd on s ur gi cal f i ndi ngs and t he s ur -
g eo n' s pr e f e r e nc e and exper i ence. Bot h wi r e and
c o nne c t i ve t i s s ue and wi r e Tef l on pi s t o ns can be
ma d e at s ur g er y. The s e ar e t he cl as s i c pr o s t he s e s
t hat ha v e s t o o d t he t est o f t i me. Th e wi r e and
c o nne c t i ve t i s s ue pr o s t hes i s c an be t ai l ored t o t he
ne e d e d l engt h o r bent o r c u r ve d i n na r r o w wi nd o ws
or pr o mi ne nt faci al ner ves ; i t al s o pr o vi des an excel -
l ent s eal .
The t echni que for maki ng an i ncus - t o- oval wi n-
d o w pr o s t hes i s i s depi ct ed i n Fi g ur e 1 3 - 5 . A pi ece
of c o nne c t i ve t i s s ue i s cut to a si ze of 2 x 3 mm.
Thi s i s pl aced on t he e d g e of t he di e and i s t i ed at
its mi d po r t i o n wi t h a 0 . 0 0 5 - mm s t ai nl es s s t eel wi r e
( Fi g. 1 3 - 5 / 1 ) . A d r o p of s al i ne hel ps handl i ng and
pl aci ng of t he t i s s ue i n t he des i r ed pos i t i on. Wi t h an
al l i gat or f or ceps ho l di ng bot h e nd s , t he knot i s t i ght -
e ne d unt i l i t d i s appe ar s i nt o t he c o nne c t i ve t i s s ue
The wi r e i s l o o ped a r o u nd t he l ar ger po s t of t he di e
wi t h t he b o t t o m of t he c o nne c t i ve t i s s ue at 4 mm
( Fi g. 1 3 - 5 8 ) . The c o nne c t i ve t i s s ue e nd i s r o t at ed
a r o u nd t he s mal l er pos t ( Fi g. 1 3 - 5 C) . Wi r e- cut t i ng
s ci s s o r s ar e us e d t o cut t he l o o p ( t o ho o k i nt o t he
i ncus ) l ar ge or s ho r t er , ac c o r d i ng t o t he si ze of t he
l ong pr o c e s s o f t he i ncus . The wi r e- cut t i ng s ci s s or s
ar e sli d up t o t he knot i n t he mi ddl e of t he graf t and
t he wi r e i s s ect i o ned. No s har p e nd s s ho ul d be left
unl es s t he pat i ent has o t o s cl er o s i s as s o ci at ed wi t h
e nd o l y mpha t i c hyd r o ps ; i n t hi s cas e, an e nd pur -
pos el y left s har p mi g ht wo r k as a "co ns er vat i ve
t ack. " The pr o s t hes i s i s left i n s al i ne unt i l us e. A
5 - mm mal l eus - t o - o val wi nd o w pr o s t hes i s i s s ho wn
i n Fi g ur e 1 3 - 5 D.
The ma ki ng of a wi r e pi s t o n i s s h o wn i n Fi g ur e
1 3 - 6 ; t he t echni que ( af t er Ro s al es ) i s s el f - expl anat or y
Procedure
The f oot pl at e i s f r act ur ed at t he mi dl i ne wi t h a
needl e ( Fi g. 1 3 - 7 4 ) . Cr e at i ng a hol e i n t he f oot pl at e
i s f r equent l y des cr i bed, but for a t ot al s t ape d e c t o my
an act ual f r act ur e i s bet t er and pr e ve nt s a f l oat i ng
f oot pl at e. The mu c o s a i s no t el evat ed at t he f oot pl at e;
t hi s avo i d s bl eedi ng a nd hel ps t o pr e ve nt s mal l , l oos e
f r ag me nt s f r o m falli ng i nt o t he ves t i bul e. If t her e i s
bl eedi ng, s mal l pi eces of Ge l f o am s at u r at e d wi t h a
s ol ut i on of MOOO e pi ne phr i ne ar e appl i ed t opi cal l y.
A No . 24 s uct i o n t i p wi t h t he f i nger off t he hol e i s
us ed. I t c a nno t be e mpha s i z e d e no u g h t hat t he
s uct i on t i p mu s t s t ay a wa y f r om t he oval wi nd o w at
all t i mes . Suct i o ni ng pe r i l ymph i n t he oval wi nd o w
can c au s e a "d e ad e a r . "
The i ncudo s t apedi al joi nt i s gent l y s e par at e d wi t h
a joi nt kni f e ( Fi g. 1 3 - 7 8 ) ; t he kni fe i s sli d be t we e n
t he i ncus and t he he ad of t he s t apes t o e ns u r e t hat
s epar at i o n i s t ot al . The s t apedi al t e nd o n i s s ect i o ned
wi t h t he j oi nt kni f e or a Bel l ucci s ci s s or s ( Fi g. 1 3 - 7 C,
D) . So me t i me s i t i s pos s i bl e t o gent l y peel i t al o ng
wi t h t he mu c o pe r i o s t e u m and l eave i t at t ac he d t o
t he l ong pr o c e s s o f t he i ncus ( Fi g. 1 3 - 7 E , F ) . Thi s
al l o ws pe r ha ps s o me pr o t ect i o n f r om s o u nd and
per mi t s bet t er vas cul ar i t y t o t he l ong pr o c e s s of t he
i ncus . I n t he unus ual e ve nt of a pr o mi ne nt pyr ami dal
e mi ne nc e , t he t e nd o n i s s ect i o ned and t he e mi ne nc e
cur et t ed. The head and c r u r a o f t he s t ape s ( s t apedi al
ar c h) ar e mobi l i z ed wi t h an ang l ed ho o k t o war d t he
pr o mo nt o r y and not i n an ant e r o po s t e r i o r di r ect i on
( whi ch c an c a u s e par t o f t he f oot pl at e t o d r o p i nt o
t he oval wi nd o w) . Us ual l y t he ar ch f r act ur es at t he
j unct i o ns of t he cr ur a wi t h t he f oot pl at e, and i s
r e mo v e d wi t h t he ang l ed ho o k or a baby al l i gat or
f o r ceps ( Fi g. 1 3 - 7 G) . Me a s u r e me nt s ar e no w ma d e
( Fi g. 1 3 - 7 H ) .
At t hi s poi . i t , t he pat i ent i s i ns t r uct ed no t t o mo v e
or t alk. Si mi l ar r e c o mme nd a t i o ns appl y t o t ho s e i n
t he o pe r at i ng r o o m. The f oot pl at e i s r e mo v e d wi t h a
H o u g h ho e or a r i ght - angl ed ho o k ( Fi g. 1 3 - 8 4 ) . I t i s
255
'"
Surgery lor Stapes Fixation
o Malleus to oval window
1---4mm--j
B
A
0.005 starnless steel wire
Gelloam
._{f-. . . . . - , . . . . - , - , - - ~
Surgery for Stapes Fixation 254
FICURE 1:\-5 FlCURE 13-<>.
256 S ur g e r y f or S t a p e s Fi xa t i o n
FIGURE 13-7
S ur ge r y f or S t a pe s Fi xa t i o n 257
i mpo r t a nt t o pl a c e t h e i ns t r ume nt j us t b a r e l y b e ne a t h
t h e f r a gme nt s t o be r e mo v e d i n o r de r t o a v o i d
d a ma g i n g t h e unde r l y i ng ve s t i bul a r s t r uc t ur e s . Bo n e
f r a gme nt s a r e e i t h e r t ot a l l y o r pa r t i a l l y r e mo v e d
( us ua l l y b y r e mo v i ng t h e po s t e r i o r t wo t h i r ds o f t h e
f o o t pl a t e ) , de pe ndi ng upo n t h e pr o c e dur e t o b e d o n e
( Fi g. 1 3 - 8 A) .
Wi t h a n a l l i ga t or f o r c e ps or a h o r i zo nt a l o pe ni ng
f o r c e ps ( wh i c h a l l o ws b e t t e r v i s ua l i za t i o n) h o l di ng
t h e b a r e e dg e o f t h e wi r e , t h e pr o s t h e s i s i s pl a c e d
( Fi g. 1 3 - 8 B ) . I f i t c a nno t be pl a c e d e a s i l y i n po s i t i o n,
i t i s r e l e a s e d a nd mo b i l i z e d b i ma nua l l y ( f or e x a mp l e ,
wi t h t h e s uc t i o n t i p a nd a Ho u g h h o e ) . I f t h e wi r e i s
b e nt dur i ng po s i t i o ni ng, i t i s b e t t e r t o us e a n e w
pr o s t h e s i s t h a n t o fix it. T h e o va l wi n d o w s h o ul d be
l eft o p e n f or t h e s h o r t e s t t i me po s s i b l e ; e x c e s s i v e
t i me o f e x po s ur e i s di r e c t l y r e l a t e d t o e f f e c t s o n
h e a r i ng. O n c e t h e wi r e c o nne c t i v e t i s s ue i s we l l
c e nt e r e d, a ddi t i o na l c o nne c t i v e t i s s ue c a n b e us e d t o
s e a l t h e wi n d o w. I f a pr o s t h e s i s wi t h o ut c o nne c t i v e
t i s s ue i s us e d, t h e o va l wi n d o w gr af t i s pl a c e d be f o r e
t h e pr o s t h e s i s ( Fi g. 1 3 - 8 C) . S u c h a gr a f t i de a l l y
s h o ul d fit pr e c i s e l y ; i t c a nno t be t o o s ma l l o r t o o
l a r ge . I f a pi s t o n i s us e d, c o nne c t i v e t i s s ue i s wr a ppe d
a r o un d it. S ma l l pi e c e s o f Ge l f o a m c a n t h e n b e pl a c e d
o v e r t h e c o n n e c b v e t i s s ue a nd a r o und t h e pr o s t h e s i s .
P i s t o n wi dt h i n a s t a p e d e c t o my i s f r o m 0. 6 t o 0. 8
mm, wh e r e a s i n a s t a p e d o t o my ( de s c r i b e d b e l o w) , i t
is 0 . 4 mm.
T h e pr o s t h e s i s i s c r i mp e d wi t h a Mc G e e c r i mpe r
o r a n a l l i ga t o r f o r c e ps . T h e c r i mpe r h a s t h e a dv a nt a ge
o f no t c l o s i ng c o mpl e t e l y ; t h us t h e r e i s l e s s c h a n c e
o f f r a c t ur i ng t h e l o ng pr o c e s s o f t h e i nc us ( Fi g. 1 3 -
8 D ) . I t i s a l s o l i ght a n d t hi n a nd d o e s no t o b s t r uc t
vi s i on. Cr i mp i n g i s d o n e i n a n a nt e r o po s t e r i o r di r e c -
t i on a n d i nv o l v e s o nl y t h e r i ng a r o und t h e i nc us ;
o t h e r wi s e , t h e pr o s t h e s i s wi l l b e b e nt a nd wi l l h a v e
t o b e c h a n g e d . Te f l o n wi r e pi s t o ns b e nd v e r y e a s i l y
i f no t c r i mp e d pr o pe r l y . T h e r o und wi n d o w r e f l e x,
t h e mo b i l i t y o f t h e o s s i c ul a r c h a i n, a nd t h e a de qua c y
o f t h e pr o s t h e s i s po s i t i o n a r e c h e c ke d a t t h i s poi nt ,
af t er wh i c h t h e f l ap I s r e po s i t i o ne d. T h e pa t i e nt i s
t h e n a s ke d i f t h e r e i s a n y i mp r o v e me n t i n h e a r i ng.
Fi na l l y , t h e e a r c a na l i s pa c ke d ( de s c r i b e d b e l o w) .
Problems and Variations
During Surgery
Bleeding. S ma l l v e s s e l s r e s po nd ve r y we l l t o t opi c a l
a ppl i c a t i o n o f c o t t o n ba l l s o r Ge l f o a m s a t ur a t e d wi t h
e pi ne ph r i ne . I n t h e f o o t pl a t e i t i s pr e f e r a b l e t o us e
Ge l f o a m i n o r de r t o a v o i d c o t t o n s t r a nds . Li do c a i ne
( Xy l o c a i ne ) wi t h e pi ne ph r i ne s h o ul d >iof be us e d i n
t h e o pe n v e s t i b ul e s i nc e i t c a n c a us e ma r k e d ve s t i b-
ul ar di s t ur b a nc e s . T h e p r e s e n c e o f a n a b n o r ma l j ug-
ul a r b ul b h a s b e e n de s c r i b e d i n a no t h e r c h a pt e r ; i f
its l o c a t i o n a l l o ws a s a f e e x pl o r a t i o n a nd s t a pe s
pr o c e dur e , i t s h o ul d no t be a c o nt r a i ndi c a t i o n. A
pe r s i s t e nt s t a pe di a l a r t e r y ( r unni ng o v e r t h e f oot -
pl a t e ) i s a v e r y unus ua l f i ndi ng. Th i s a r t e r y i s fair l y
l a r ge a nd s h o j l d no t b e c o nf us e d wi t h s ma l l but
p r o mi n e n t muc o pe r i o s t e a l v e s s e l s i n t h e f o o t pl a t e . I f
a s ma l l o p e n i n g on t h e f o o t pl a t e c a n be ma d e a nd a
s ma l l pi s t o n pl a c e d, t h e pr o c e dur e c a n b e do ne ;
o t h e r wi s e , t h e o pe r a t i o n s h o ul d no t t a ke pl a c e .
Ob l i t e r a t i o n o f t h e r o un d wi n d o w a nd f i xa t i on o f
t h e ma l l e us h a v e b e e n de s c r i b e d.
Accidental Dislocation o f the Incus. T h e i nc us s h o ul d
be pa l pa t e d. I f t h e di s l o c a t i o n i s pa r t i a l a nd t h e i nc us
mo v e s wi t h t h e ma l l e us , t h e pr o s t h e s i s i s pl a c e d a s
us ua l . If i t i s t ot a l l y l ux a t e d, a ma l l e us - t o - o v a l wi n-
do w pr o s t h e s i s ( or a n e qui v a l e nt pr o s t h e s i s , a s de -
s c r i be d i n Ch a p t e r 12) i s s ub s t i t ut e d.
Fr a c t ur e o f t h e l o ng pr o c e s s o f t h e i nc us wh i l e
c r i mpi ng t h e pr o s t h e s i s i s r a r e ; i f i t h a p p e n s , t h e
pr o s t h e s i s c a n b e c r i mpe d o n t h e r e ma i ni ng s t r ut
( Fi g. 1 3 - 9 4 ) . I f t h i s i s i mpo s s i b l e , a ma l l e us - t o - o va l
wi n d o w pr o s t h e s i s ( or i t s e qui v a l e nt ) c a n b e us e d
i ns t e a d.
Pain. An o c c a s i o na l pa t i e nt mi gh t c o mpl a i n o f pa i n
wh e n t h e mi ddl e e a r mu c o s a i s t o uc h e d. To pi c a l
a ppl i c a t i o n o f ' : . % l i do c a i ne i n c o t t o n o r Ge l f o a m
pl e dge t s s uf f i c e s .
Prominent Promontory. Th i s c a n be dr i l l e d c a r e f ul l y
i n o r de r t o pr o* i de a de qua t e vi s ua l i za t i o n ( Fi g. 1 3 -
9 C) . D e p e n d i n g upo n t h e v i s ua l i za t i o n o b t a i ne d, a
s ma l l pi s t o n or A wi r e c o nne c t i v e t i s s ue pr o s t h e s i s i s
pl a c e d. An a b no r ma l ( o pe n o r r e dunda nt ) s e v e nt h
ne r v e i n i t s e l f i s no t a c o nt r a i ndi c a t i o n. I t ma y be
po s s i bl e t o mo b i l i z e i t ge nt l y wi t h a b l unt h o o k,
a l l o wi ng a n o p e n i n g t o b e ma d e i n t h e f o o t pl a t e f or
pl a c e me nt o f a pr o s t h e s i s . S o me t i me s , de pe ndi ng
upo n t h e a n a t o mi c c o ndi t i o ns , a wi r e c o nne c t i v e
t i s s ue pr o s t h e s i s c a n be b e nt t o fit. On o c c a s i o n, a n
of f s e t R o b i n s o n pr o s t h e s i s fits pr e c i s e l y . Fl e xi bi l i t y
a n d us e o f a pr o s t h e s i s t o fit t h e n e e d a r e pa r a mo unt ;
t h e c o ur s e o f a c t i o n s h o ul d r e f l e c t t h e a na t o mi c a nd
f unc t i o na l n e e d s o f t h e pa t i e nt a nd t h e r a t i ona l a nd
s a f e a ppr o a c h o f t h e s ur g e o n.
Narrow Oval Window. A na r r o w wi n d o w c a n be
s e c o n d a r y t o a pr o mi ne nt o v e r l y i ng pr o mo nt o r y ; i t
c a n a l s o r e pr e s e nt a c o nge ni t a l de f e c t , wh i c h not
u n c o mmo n l y l e a ds t o a pe r i l y mph " g u s h e r . " It i s
a l s o ve r y i mpo r t a nt t o a s s e s s t h e f aci al ne r v e a n d its
r e l a t i o ns h i p t o t h e f o o t pl a t e ( Fi g. 1 3 - 9 D ) . I f t h e
wi n d o w i t s e l f i s qui t e na r r o w a n d a c o ng e ni t a l de f e c t
i s s us pe c t e d, a s ma l l o pe ni ng c a n be ma d e wi t h a
258 Surgery for Stapes Fixation
Surgery for Stapes Fixation 259
c
A
A
HGURE 1:1-8
FIGURE 13-9.
S ur ge r v f or S t a pe s Fi xa t i o n 2 61
s ma l l , s h a r p ne e dl e ; i f a g u s h e r i s f o und, i t i s c o v e r e d
wi t h c o nne c t i v e t i s s ue a nd Ge l f o a m. T h e h e a d o f t h e
pa t i e nt i s r a i s e d a n d t h e pr o c e dur e i s t e r mi na t e d. I f
t her e i s no gus h e r , t h e s ma l l o pe ni ng c a n be e nl a r ge d
t o pl a c e a 0 . 4 - mm pi s t o n or a t h i n pr o s t h e s i s .
Cerebrospinal Fluid Leak. A " g u s h e r " is u n c o mmo n ,
and i s ge ne r a l l y ( but no t e x c l us i v e l y ) s e e n i n c a s e s
of a c o nge ni t a l l y f i xed s t a pe s ( a nd a pa t e nt c o c h l e a r
a que duc t ) . T h e pa t i e nt ' s h e a d i s e l e v a t e d a nd a l a r ge
c o nne c t i v e t i s s ue wi r e pr o s t h e s i s us e d f or a s e a l ,
wi t h a ddi t i o na l c o nne c t i v e t i s s ue .
Dry Vestibule. If t h e pe r i l y mph i s a c c i de nt a l l y s uc -
t i one d o ut o f t h e o va l wi n d o w ( t h e s uc t i o n t i p s h o ul d
nettcr be put i nt o t h e o va l wi n d o w [ Fi g. 1 3 - 1 0 E, F] ) ,
the wi n d o w wi l l r ef i l l . If i t do e s no t , a f e w dr o ps of
s al i ne a r e us e d t o fill it. Bl o o d mi gh t s t i mul a t e a n
i nf l a mma t o r y r e a c t i o n i n t h e v e s t i b ul e .
Floating Footplate. Th i s r e f e r s to a f o o t pl a t e t ha t
b e c o me s mo b i l e b e f o r e a n o pe ni ng i s ma d e i n i t a nd
after r e mo v a l o f t h e a r c h ( t h e s upe r s t r uc t ur e c o ns i s t -
ing of t h e h e a d a nd c r ur a ) . T h i s i s a di f f i cul t c h a l -
l enge. O n e wa y t o a v o i d i t i s t o f r a c t ur e t h e f o o t pl a t e
bef or e r e mo v i n g t h e a r c h . A f l oa t i ng f o o t pl a t e t e nds
t o o c c ur i n a s t a pe s t h a t h a s b e e n pr e v i o us l y mo b i -
l ized or i n o n e wi t h po o r f i xa t i on.
S o me t i me s t h e f o o t pl a t e c a n b e c a r e f ul l y r e mo v e d
wi t h a n a ng l e d h o o k. I f t h i s i s i mpo s s i b l e , a n o pe ni ng
can be ma d e wi t h a d i a mo n d b ur o r s ma l l b ur i n t h e
a nt e r oi nf e r i or ma r gi n, a nd t h e f o o t pl a t e r e mo v e d
wi t h a h o o k ( Fi g. 1 3 - 1 0 4 , 8 ) . I f t hi s t o o i s i mpo s s i b l e
and t h e f o o t pl a t e i s no t de pr e s s e d, f a s c i a c a n be
pl aced o v e r i t a nd a s h o r t e r pi s t o n pl a c e d. If
r ef i xat i on o c c ur s ( wh i c h i s l i ke l y ) , t h e f oot pl a t e
can be r e vi s e d wi t h be t t e r c h a nc e s o f s uc c e s s ( Fi g
1 3 - 1 0C) .
Depressed Fragments. De pr e s s e d f r a gme nt s c a n be
r e mo ve d c a r e f ul l y wi t h a h o o k, but " f i s h i ng" i n t h e
ve s t i bul e s h o ul d be a v o i de d; i t i s b e t t e r t o l e a v e t h e
f r a gme nt s i n t h e v e s t i b ul e a nd us e a mp l e a mo u n t s
o f s t e r o i ds , t opi c a l l y a nd pa r e nt e r a l l y . S o me a ut h o r s
r e c o mme nd pl a c i ng a f e w dr o ps of b l o o d i n t h e
ve s t i bul e a nd a l l o wi ng t h e m t o cl ot ; wh e n t h e c l ot i s
r e mo ve d t h e f r a gme nt s ma y c o me o ut wi t h i t ( Fi g.
1 3 - 1 0D) .
Obliterative Otosclerosis
I f an o bl i t e r a t i ve f o c us i s f o undf o r e x a mpl e , i f
the o va l wi n d o w h a s no di s c e r ni b l e f o o t pl a t e o wi ng
t o o t o s c l e r o t i c c h a n g e ( Fi g. 1 3 - 1 1 4 ) t h e pr o c e dur e
i s di f f e r e nt . If t h e pa t i e nt i s a c h i l d wi t h an a c t i ve
f ocus , i t i s b e t t e r t o de l a y t h i s pr o c e dur e . ( Th e
que s t i on o f o pe r a t i ng o n c h i l dr e n wi t h o t o s c l e r o s i s
i s no t a n e a s y o ne ; i n ge ne r a l , i t s e e ms be t t e r t o
de l a y s uc h pr o c e dur e s b ut s o me s ur g e o ns do pe r f o r m
t h e m, r e po r t e dl y wi t h g o o d r e s ul t s . )
A t h i c k f o o t pl a t e mu s t be t h i nne d wi t h a 0. 6 - t o
1- mm c ut t i ng o r d i a mo n d b ur wi t h s l o w r ot a t i on
( Fi g. 1 3 - 1 1 8 ) . Th i s i s d o n e a nt e r o po s t e r i o r l y , s a uc e r -
i zi ng e v e nl y a nd a ppl y i ng j us t e n o u g h pr e s s ur e o v e r
t h e f o o t pl a t e t o be e f f e c t i ve . Bo n e dus t i s me t i c u-
l ous l y r e mo v e d . I f t h e f o o t pl a t e i s t h i nne d e v e nl y ( t o
a t hi n b l ui s h pl a t e ) , a s ma l l ( 0 . 5 - mm) o pe ni ng i s
ma d e a n d a pi s t o n s ur r o un d e d by c o nne c t i v e t i s s ue
i s pl a c e d ( Fi g. 1 3 - 1 1 C- E) . L e s s c o mmo n l y , t h e f oot -
pl a t e i s f r a c t ur e d a nd r e mo v e d , a nd a gr af t i s pl a c e d.
Stapedotomy
Th i s pr o c e dur e h a s g a i ne d ma n y a dv o c a t e s i n
r e c e nt y e a r s b e c a us e i t h a s b e e n s ug g e s t e d t h a t i t
i nv o l v e s l e s s r i s k o f i nne r e a r d a ma g e , l e s s c h a n c e o f
a dh e s i o ns b e t we e n t h e gr af t a nd v e s t i b ul a r c o nt e nt s ,
a nd l e s s mo b i l i t y o f t h e o va l wi n d o w a s a wh o l e . As
wi t h al l s ur gi c a l i nno v a t i o ns , t i me a nd e x pe r i e nc e
wi l l t el l . T h e pr o c e dur e a l s o c a n be do ne wi t h a l a s e r
( s e e Ch a p t e r 1 4 ) . T h e o pe r a t i o n i s s i mi l a r t o a c l a s s i c
s t a pe de c t o my , up t o t h e po i nt o f o p e n i n g t h e f oot -
pl a t e . T h e n t h e f o o t pl a t e i s pe r f o r a t e d wi t h a s h a r p
ne e dl e ( or s pe c i a l mi c r o dr i l l ) i n t h r e e di f f e r e nt s po t s .
En l a r g e me n t o f t h e s e o p e n i n g s i s do ne v e r y c a r e f ul l y
wi t h a ngl e d h o o ks , t r y i ng t o l e a ve a s i ngl e c e nt r a l
o pe ni ng t h a t i s s l i gh t l y l a r ge r t h a n 0. 4 mm. T h e s i ze
c a n be me a s u r e d wi t h a 0 . 4 - mm me a s ur i ng r od. Th i s
s t e p c a n b e d o n e wi t h o ut r e mo v i ng t h e s t a pe s a r c h ,
a v o i di ng mo b i l i za t i o n o f t h e s t a pe s . O n c e t h i s i s
do ne , t h e i nc udo s t a pe di a l j o i nt i s s e pa r a t e d a nd t h e
c r ur a a r e sectioned wi t h c r ur o t o my s c i s s o r s ; t h e pr o s -
t h e s i s i s t h e n pl a c e d o v e r t h e i nc us a nd i nt o t h e
f o o t pl a t e o pe ni ng a nd s ur r o un d e d wi t h c o nne c t i v e
t i s s ue .
Stapes Interposition
I n t h e p r e s e n c e of a wi de ni c h e , a n a nt e r i o r f i xa -
t i on, a nd a h e a l t h y po s t e r i o r c r us , a n i nt e r po s i t i o n
pr o c e dur e is a r a t i o na l a l t e r na t i ve . It r e pr e s e nt s a
s a f e a nd l ogi c a l a ppr o a c h b ut i s di f f i cul t t o pe r f o r m
pr o pe r l y , r e qui r i ng a bi l i t y a nd e x pe r i e nc e . T h e pr o-
c e dur e i nv o l v e s r e mo v i ng a po r t i o n of t h e f o o t pl a t e
( f i xe d) a n d mo b i l i zi ng t h e po s t e r i o r c r us ( a s a "pr o s -
t h e s i s " ) o v e r a n unde r l y i ng gr a f t , t h us r e - e s t a bl i s h i ng
t h e c o nt i nui t y a nd mo bi l i t y o f t h e o s s i c ul a r c h a i n.
!
S ur ge r y f or S t a pe s Fi xa t i o n 26 3
I ni t i a l l y t h e a nt e r i o r c r us i s s e c t i o ne d wi t h a ng l e d
c r ur o t o my s c i s s o r s ( Fi g. 1 3 - 1 2 / 1 ) . P o r t ma nn ( a n a d-
v o c a t e o f t h i s pr o c e dur e ) r e c o mme n d s s e c t i o ni ng i n
t h e ma i n a xi s o f t h e s t a pe s , i nt r o duc i ng t h e s c i s s o r s
b e t we e n t h e ma l l e us a n d t h e i nc us , s i nc e t h e s i mpl e r
a ppr o a c h t h r o ugh t h e p r o mo n t o r y c a r r i e s t h e r i s k o f
f r a c t ur i ng t h e s t a pe s a t a no t h e r s i t e . T h i s i s f o l l o we d
b y s e c t i o ni ng o f t h e s t a pe di a l t e ndo n. T h e po s t e r i o r
c r us i s t h e n c a r e f ul l y f r a c t ur e d wi t h a mi c r o h o o k at
its j unc t i o n wi t h t h e f o o t pl a t e . Wh e n t h e po s t e r i o r
c r us i s f r ee ( f r om muc o s a l a dh e s i o ns a s we l l ) , i t i s
mo b i l i z e d a nt e r i o r l y wh i l e t h e i nc us i s l i f t ed wi t h a
Ho u g h h o e ( t h us a v o i di ng f r a c t ur e s i n t h e po s t e r i o r
c r us ) ( Fi g. 1 3 - 1 2 B ) . T h e f o o t pl a t e i s f r a c t ur e d a nd t h e
po s t e r i o r t wo t h i r ds a r e r e mo v e d ( Fi g. 1 3 - 1 2 C a nd
Fi g. 1 3 - 1 3 A ) . A gr af t i s pl a c e d a n d t h e po s t e r i o r c r us
i s r e po s i t i o ne d o v e r t h e gr af t ( wh i l e t h e i nc us i s
l i f t e d) , r e - e s t a b l i s h i ng o s s i c ul a r c o nt i nui t y a nd mo -
bi l i t y ( Fi g. 1 3 - 1 3 B - D ) .
S o me s ur g e o ns pe r f o r m t h i s pr o c e dur e b y r e mo v -
i ng pa r t o f t h e a nt e r i o r c r us a nd t h e a nt e r i o r h a l f o f
t he f o o t pl a t e ( a n a nt e r i o r c r ur o t o my ) . T h e r e ma i ni ng
mo b i l e po s t e r i o r c r us a nd unde r l y i ng mo b i l e f oot -
pl a t e a r e mo b i l i z e d t o wa r d t h e c e nt e r o f t h e ova l
wi n d o w ( o v e r t h e gr a f t ) . T h e s t a pe di a l t e ndo n mi gh t
or mi g h t no t be s e c t i o ne d, a c c o r di ng t o ne e d. A
po s t e r i o r c r ur o t o my a l s o c a n b e d o n e i n r e v e r s e
f a s h i o n, b ut us ua l l y t h e po i nt o f f o o t pl a t e f i xa t i on i s
a nt e r i o r .
Malleus-to-Oval
Window Prosthesis
T h e a i m of t h i s pr o c e dur e i s t o pl a c e a wi r e
pr o s t h e s i s f r om t h e h a ndl e o f t h e ma l l e us t o t h e o va l
wi n d o w. It i s i mpo r t a nt t o pl a c e t h e wi r e un d e r a
s ub pe r i o s t e a l po c ke t i n t h e h a ndl e o f t h e ma l l e us , a s
c l o s e t o t h e s h o r t pr o c e s s a s po s s i bl e .
S uc h pr o s t h e s e s a r e c o mme r c i a l l y a va i l a bl e , b ut a
wi r e c o nne c t i v e t i s s ue c a n b e ma d e . S t a p e s pr o s t h e s i s
wi r e a nd a b e ndi ng di e a r e us e d t o ma nuf a c t ur e a
pr o s t h e s i s ; o nl y t h e l a r ge po s t of t h e di e i s us e d t o
s h a pe t h e " c r o o k " o r " h a n d l e " ( s e e Fi g. 1 3 - 5 ) .
Wi t h a j o i nt kni f e , a n i nc i s i o n i s ma d e t h r o ugh
t he mu c o p e r i o s t e u m o n t h e unde r s ur f a c e o f t h e h a n-
dl e of t h e ma l l e us , c r e a t i ng a s ub pe r i o s t e a l po c ke t
( Fi g. 1 3 - 1 4 / 1 ) . On o c c a s i o n i t i s ne c e s s a r y ( b e c a us e
o f c o nt a c t wi t h t h e o v e r l y i ng t y mp a n i c me mb r a n e )
t o pl a c e t h e pr o s t h e s i s a t t h e ne c k o f t h e ma l l e us .
T h e s t a pe s a r c h i s r e mo v e d fir st, a n d t h e pr o s t h e s i s
i s pl a c e d t o e n s ur e c o r r e c t l e ngt h . I ni t i a l l y t h e pr o s -
t h e s i s i s h e l d i n a ma n n e r s i mi l a r t o a s t a pe s pr o s -
t h e s i s , but i t i s pl a c e d at a r i gh t a ngl e t o t h e ma l l e us
h a ndl e ( Fi g. 1 3 - 1 4 6 ) . O n c e i t i s o v e r t h e ma l l e us
h a ndl e ( unde r t h e pe r i o s t e a l po c ke t ) , i t i s t ur ne d
d o wn s o t h a t i t i s pe r pe ndi c ul a r t o t h e h a ndl e ; t h i s
ma n e u v e r ma k e s po s i t i o ni ng e a s i e r . I f t h e l e ngt h i s
s a t i s f a c t o r y , t h e pr o s t h e s i s i s di s pl a c e d a nt e r i o r l y ,
t h e f o o t pl a t e i s r e mo v e d , a n d a c o nne c t i v e t i s s ue
gr af t i s pl a c e d o v e r t h e o va l wi n d o w. T h e pr o s t h e s i s
i s po s i t i o ne d a nd t h e n t i gh t e ne d b i ma nua l l y ( wi t h
a n a ng l e d h o o k a nd s uc t i o n t i p o r b l unt i ns t r ume nt )
a l o ng t h e unde r s ur f a c e o f t h e ma l l e us ( Fi g. 1 3 - 1 4 C) .
I t s h o ul d b e r e me mb e r e d t h a t , r e ga r dl e s s o f h o w
we l l t h e pr o s t h e s i s mi g h t f i t , i t i s a na t o mi c a l l y a nd
f unc t i o na l l y l e s s e f f i c i e nt t h a n a s t a p e d e c t o my pr o s -
t h e s i s ; a t t h e s a me t i me , t h e o va l wi n d o w i s s ub j e c t e d
t o mo r e t r a uma ( t h e mo b i l i t y o f t h e ma l l e us i s gr e a t e r
t h a n t h a t o f t h e i nc us a n d h a s l e s s d a mp e n i n g e f f e c t ) .
Closure and Packing
T h e f l ap i s c a r e f ul l y r e po s i t i o ne d. If a s ma l l t e a r i s
pr e s e nt , t h e e dg e s a r e c a r e f ul l y a ppr o x i ma t e d. I f
ne c e s s a r y , s ma l l pi e c e s o f Ge l f o a m o r c o nne c t i v e
t i s s ue c a n b e us e d, a nd t h e f l ap l eft s o me wh a t l o o s e .
Fo r l a r ge r pe r f o r a t i o ns , a gr af t i s pl a c e d a nd a mpl e
a mo u n t s o f a nt i bi o t i c s a nd a nt i - i nf l a mma t o r y me di -
c a t i o ns a r e us e d. P a c ki ng t e c h ni que s h a v e b e e n de -
s c r i be d. T h e pa t i e nt mus t l i e wi t h t h e o pe r a t e d e a r
up a nd i s c l o s e l y f o l l o we d po s t o pe r a t i v e l y ; t h e ne e d
t o a v o i d s t r a i ni ng, l i f t i ng, o r undue e f f or t c a nno t be
e mp h a s i z e d e n o u g h . Co mp l i c a t i o n s c o nt i nue t o b e
ve r y po s s i b l e unt i l c o mp l e t e h e a l i ng h a s o c c ur r e d (at
f our t o s i x we e k s ) a n d ma y stil l o c c ur t h e r e a f t e r .
S o me f a i l ur e s c a n be t r a c e d t o o v e r c o nf i de nc e i n t h e
o pe r a t i v e pr o c e dur e . I t h a s b e e n a r gue d t h a t pr o ph y -
l act i c a nt i b i o t i c s a r e unne c e s s a r y ; h o we v e r , t h e a u-
t h o r s s t r o ngi y r e c o mme n d t h e us e o f i nt r a o pe r a t i v e
a nd po s t o pe r a t i v e a nt i bi o t i c s .
J
Complications
As i n a n y s ur gi c a l pr o c e dur e , a wa r e n e s s a nd pr e-
v e nt i o n o f po s s i b l e c o mpl i c a t i o ns a r e t h e ke y s . Ad-
e qua t e pr e o pe r a t i v e e v a l ua t i o n, a we l l - de f i ne d di a g-
no s i s , a n d r a t i o na l s ur gi c a l pl a ns a r e o f pa r a mo unt
i mpo r t a nc e . T h e pa t i e nt o n t h e o pe r a t i ng t a bl e i s
a s s u me d t o h a v e h a d a t h o r o ugh ove r a l l c h e c k ( i n-
c l udi ng c a r di o v a s c ul a r s t a t us , a l l e r gi e s , e ndo c r i no -
l ogi c pr o b l e ms , a nd s o o n) .
!
264 Surgery for Stapes Fixation
B
FIGURE 13-12.
c
Surgery for Stapes Fixation 265
FIGURE 13-13.
Dy s g e us i a f o l l o wi ng i nj ur y t o t h e c h o r da t y mpa ni
i s c h a r a c t e r i ze d by t i ngl i ng or a me t a l l i c t a s t e on t h e
t o n g u e o n t h e o pe r a t e d s i de , o r b o t h . Th i s a l wa y s
i mpr o v e s , but t h e r e a s o n f or t h e i mp r o v e me n t i s
unc l e a r .
I nf e c t i o n i s r a r e , e s pe c i a l l y i f a d e q u a t e pr o ph y l a x i s
( i nc l udi ng me t i c ul o us c l e a ns i ng o f t h e e a r c a na l ) h a s
b e e n unde r t a ke n. I f i t o c c ur s , t h e pa c ki ng s h o ul d be
r e mo v e d , c ul t ur e s o b t a i ne d (if po s s i b l e ) , a nd a nt i -
bi o t i c s gi v e n ( or c h a n g e d ) t o pi c a l l y a nd pa r e nt e r a l l y .
I nf e c t i o n ma y l e a d t o l a by r i nt h i t i s a nd s h o ul d be
t r e a t e d a ggr e s s i v e l y .
Fa c i a l pa l s y ma y f ol l ow i nj e c t i o n o f l ocal a ne s -
t h e t i c s , b ut s h o ul d b e o nl y t e mpo r a r y . Pa l s y i mme -
di a t e l y f o l l o wi ng s t a p e d e c t o my pr o b a b l y s i gna l s
d a ma g e t o a n e x p o s e d ne r v e i n t h e ova l wi n d o w
dur i ng t h e pr o c e dur e . S ur gi c a l r e - e x pl o r a t i o n i s in-
di c a t e d. I t s h o ul d be ke pt i n mi nd t ha t d a ma g e
pr o b a b l y i s r e s t r i c t e d t o l ocal e d e ma o r punc t ur i ng
o f t h e ne r v e ; s e c t i o ni ng o f t h e ne r v e i s e x t r e me l y
r ar e* De l a y e d pa r a l y s i s mus t be e v a l ua t e d, a nd i s
t r e a t e d i n t h e s a me ma n n e r a s Be l l ' s pa l s y .
Ve r t i go i s f ai r l y c o mmo n dur i ng t h e first f e w
po s t o pe r a t i v e da y s ; h o we v e r , s y mp t o ms s h o ul d b e
mi l d, s h o r t l i ve d, a n d r e s po ns i v e t o r e s t a nd ve s t i b-
ul a r s e da t i v e s . Ve r t i g i no us s y mp t o ms s h o ul d no t b e
t a ke n l i gh t l y; t h e y c o ul d be a wa r ni ng s i gn, wh i c h
l eft un a t t e n d e d mi g h t l e a d t o i r r e ve r s i bl e s e ns o r y
de a f ne s s . P e r s i s t e nc e o f ve r t i go o r s e v e r e ve r t i go
mi g h t be i ndi c a t i ve of a pe r i l y mph f i s t ul a, a t hi n or
l e a ky gr a f t , pe r i pr o s t h e s i s l e a k a r o un d a Te f l o n pi s -
t on ( a s s o c i a t e d wi t h f l uc t ua t i ng h e a r i ng l o s s ) , a pr o s -
t h e s i s t ha t i s t o o l o ng, l a by r i nt h i t i s , o r r e pa r a t i ve
g r a n u l o ma . Ope r a t i v e c a us e s i nc l ude t r a uma dur i ng
t h e o pe r a t i o n o r l o o s e b o n e f r a gme nt s i n t h e ve s t i -
bul e . Ea r l y t r a uma or b a r o t r a uma mnv di s pl a c e a
pr o s t h e s i s , l e a di ng t o a f i s t ul a.
I f t h e s e s y mp t o ms pe r s i s t i n s pi t e of t h e r a pe ut i c
me a s u r e s a nd c l i ni c a l j ud g me n t s ug g e s t s a c o mpl i -
c a t i o n, or i f t h e r e i s a s e ns o r y h e a r i ng i nv o l v e me nt ,
e x pl o r a t i o n i s i ndi c a t e d. Wh e n r e v i s i ng a s t a pe de c -
t o my ( or a ny e a r pr o c e dur e ) , s pe c i a l c a r e mus t b e
t a ke n i n l i f t i ng a t hi n s ki n f l ap. Ov e r l o o ki ng t hi s
i mpo r t a nt po i nt mi g h t l e a d t o s e r i o us a nd u n n e c e s -
s a r y t e a r s i n t h e f l ap o r t y mpa ni c me mb r a n e . I n
ge ne r a l , no t mu c h gr af t i s r e mo v e d wh e n r e vi s i ng,
a nd c o nne c t i v e t i s s ue i s pl a c e d a r o un d t he ova l
wi n d o w gr af t . T h e r o und wi n d o w i s e v a l ua t e d f or
t e a r s ; i f i t i s que s t i o na b l e , a s ma l l pi e c e of Ge l f o a m
c a n b e us e d t o o b l i t e r a t e t h e ni c h e . I f t h e pr o s t h e s i s
i s f o und t o be t o o l o ng, t h e wi r e c a n be ge nt l y be nt
t
I
b i ma n u a l l y a n d t h e pr o s t h e s i s s h o r t e ne d. I f t h i s i s
i mpo s s i b l e "or i na de qua t e , t he pr o s t h e s i s s h o ul d be
r e pl a c e d. r t e pl a c e me nt c a r r i e s t h e r i s k o f pul l i ng
ve s t i bul a r a dh e s i o ns . Ve r t i go l e a di ng t o s e ns o r y
de a f ne s s i s r a r e af t er o n e mo nt h , but c a n o c c ur up
t o t h r e e t o i x y e a r s l a t e r . On o c c a s i o n, ve r t i go mi gh t
pe r s i s t f or y e a r s , e v e n wi t h go o d h e a r i ng; i t ma y
e v e nt ua l l y r e qui r e s ur gi c a l c o r r e c t i o n.
P a t i e nt s us ua l l y h a v e a mi l d s e ns a t i o n o f e c h o i ng
a l o ng wi t h t i nni t us o f no s i gni f i c a nc e , but t i nni t us
a nd a f e e l i ng of r e s o na nc e ma y i ndi c a t e f i s t ul ae or
l a by r i nt h i t i s , e s pe c i a l l y i f a c c o mp a n i e d by ve r t i go .
Re pa r a t i v e g r a nul o ma i s o n e o f t h e f e w e me r g e n -
c i e s f o l l o wi ng s t a p e d e c t o my . I t o c c ur s o n e t o t wo
we e k s a f t e r s ur ge r y a nd i s c h a r a c t e r i z e d b y di mi n-
i s h e d h e a r i ng f o l l o wi ng a n i ni t i al ga i n. Addi t i o na l
s y mp t o ms i nc l ude a ur a l f ul l ne s s , l o s s o f di s c r i mi na -
t i on, a n d di s e qui l i b r i um. T h e t y mpa ni c me mb r a n e
ma y be dul l , r e d, a n d t h i c ke ne d, wi t h a h y pe r v a s -
c ul a r f l ap a n d i nf l a mma t i o n i n t h e po s t e r o s upe r i o r
qua dr a nt . R e mo v a l o f t h e g r a nul o ma i s d o n e i n a
pi e c e me a l f a s h i o n, a nd f as ci a i s pl a c e d o v e r t h e gr af t .
T h e pr o s t h e s i s c a n be r e pl a c e d by a n e w c o nne c t i v e
t i s s ue wi r e pr o s t h e s i s . Gr a n u l o ma s h a v e not b e e n
s h o wn t o r e c ur .
Co nduc t i v e h e a r i ng l o s s e s o c c ur r i ng af t er i ni t i al
ga i ns a r e i ndi c a t i o ns f or r e vi s i o n. A pr ude nt wa i t i ng
pe r i o d i s s ugge s t e d. A pe r f o r a t e d t y mpa ni c me m-
b r a ne wi l l r e qui r e a my r i ngo pl a s t y . A de l a y e d c o n-
duc t i v e h e a r i ng l o s s wi t h a n i nt a c t t y mpa ni c me m-
b r a ne s ug g i s t s pr o b l e ms wi t h t h e pr o s t h e s i s . I f t h e r e
ar e a d h e s i o n s a r o und t h e pr o s t h e s i s , t h e y s h o ul d b e
s h a r pl y e x c i s e d a nd Ge l f i l m or S i l a s t i c pl a c e d. I f
ne c e s s a r y , t he pr o s t h e s i s i s r e pl a c e d. P r o s t h e s e s t ha t
ar e di s pl a c e d c a n be e i t h e r r e po s i t i o ne d o r r e pl a c e d;
i f t he l a t t e r , t h e y a r e ge nt l y l o o s e ne d f r om t h e l o ng
pr o c e s s o f t h e i nc us wi t h a ngl e d h o o k s b i ma nua l l y .
I f t h i s i s i mpo s s i b l e , t h e y c a n be s e c t i o ne d wi t h s ma l l
s c i s s o r s a n d r e pl a c e d. I f ne c r o s i s o f t h e l o ng pr o c e s s
of t h e i nc us i s pr e s e nt , t h e pr o s t h e s i s i s pl a c e d i n
t h e r e mn a n t . I f t h i s i s i mpo s s i b l e , a ma l l e us - t o - o va l
wi n d o w pr o s t h e s i s ( or pl a c e me nt o f a b o n e gr af t o r
T O R P ) i s i ndi c a t e d.
A pi s t o n i s us e d i f t h e r e i s r e c ur r e nt b o n e de po -
s i t i on wi t h c l o s ur e o f t h e o va l wi n d o w. I f t h e f o c us
i s a c t i ve a nd r i s k i s i nv o l v e d, t h i ngs s h o ul d be l eft
a s t h e y a r e for t h e t i me b e i ng. I t s h o ul d be ke pt i n
mi nd t h a t ' . he r e s ul t s o f r e vi s i o n s t a pe de c t o my a r e
not s o g o o d a s i n pr i ma r y pr o c e dur e s ; a t t h e s a me
t i me , v e s t i b ul a r i nv o l v e me nt wi t h s e c o n d a r y s e ns o r y
h e a r i ng l o s s i s mo r e l i ke l y.
S ur ge r y f or S t a pe s Fi xa t i o n 26 7
2 68 S ur g e r y for S t a p e s Fi xa t i on
Pertinent Histopathology
F I GURE 1 3 - 1 5
Th i s h o r i zo nt a l s e c t i o n s h o ws a l a r ge o t o s c l e r o t i c
f oc us f i xi ng t h e s t a pe s a nt e r i o r l y a nd po s t e r i o r l y . T h e
s t a pe s f o o t pl a t e i s t h i c ke ne d. No t e t h a t t h e b r a nc h e s
of ( a c o b s o n ' s ne r v e on t h e p r o mo n t o r y (parallel it-
rows) a r e a l mo s t e nt i r e l y s ur r o unde d by o t o s c l e r c ' . i c
b o n e .
S ur ge r y f or S t a pe s Fi x a t i o n 2 69
F I GURE 1 3 - 1 6
Th i s s e c t i o n a t t h e l e ve l o f t h e o v a l wi n d o w a r e a f o o t pl a t e h a s b e e n e x c i s e d; t h e s i t e i s e v i de nt . Th e
i s f r o m t h e t e mpo r a l b o n e o f a n i ndi v i dua l wh o h a d v e s t i b ul e i s i nt a c t . No t e t h e c l o s e pr o x i mi t y o f t h e
a s uc c e s s f ul s t a p e d e c t o my . Pa r t o f t h e o t o s c l e r o t i c v e s t i b ul a r c o nt e nt s .
1
2 70 S ur ge r y f or S t a pe s Fi xa t i o n
Cochlea
F I G UR E 1 3 - 1 7
Th i s s e c t i o n i s f r om t h e t e mpo r a l b o n e o f a n
i ndi vi dua l wh o u n d e r we n t a s t a pe de c t o my wi t h a
pi s t o n pr o s t h e s i s . T h e s i t e o f pl a c e me nt i s e v i de nt ; pl a c e d s ub s e que nt l y
i t c a n be s e e n t h a t t h e pi s t o n wa s t o o de e p a nd
i mpi ng e d o n t h e v e s t i b ul a r s t r uc t ur e s . T h e s ur g i c i j
r e s ul t wa s not i de a l , a nd t h e pa t i e nt h a d t wo pi s t o n ;
S ur ge r y f or S t a pe s Fi x a t i o n 2 71
F I GURE 1 3 - 1 8
Th i s h o r i zo nt a l s e c t i o n s h o ws a s t a pe s f i xed by c o ndi t i o ns , t h e mi ddl e e a r pr o c e s s wo ul d i mme di -
o t o s c l e r o s i s a nd a mi ddl e e a r c a vi t y wi t h c h a n g e s a t e l y pe ne t r a t e t h e v e s t i b ul e , wi t h di s a s t r o us po t e n-
c a us e d b y ot i t i s me di a . T h e s e c t i o n s h o ws v e r y tial c o mpl i c a t i o ns . ( S o me i nf l a mma t i o n o f t h e ve s t i -
c l e a r l y t h a t i f t h e f o o t pl a t e we r e r e mo v e d unde r t h e s e b ul e i s e v i de nt . )
Fi
CHAPTER 14
Lasers in
Otologic Surgery
T h e wo r d l a s e r i s a n a c r o n y m f or l i ght a mpl i f i c a -
t i on by s t i mul a t e d e mi s s i o n o f r a di a t i o n. I n t h e e a r l y
2 0t h c e nt ur y Al b e r t Ei ns t e i n pr e di c t e d t h a t t h i s f or m
o f e ne r g y e x i s t e d. I t wa s no t unt i l 1 9 6 0 t ha t T h e o d o r e
Ma i mo n d e v e l o p e d t h e fir st wo r ki ng l a s e r , ma d e o f
a r ub y c r y s t a l . Ne x t , t h e ga s l a s e r wa s de v e l o pe d by
Al e c J a v o n i n 1 9 6 1 . F r o m t h e s e e a r l y l a s e r s h a v e
c o me t h e ma n y a dv a nc e d mo de l s i n me di c a l us e
t o da y .
A n u mb e r o f l a s e r s y s t e ms a r e c ur r e nt l y a va i l a bl e
f or us e i n t h e h e a d a nd ne c k a r e a . T h e a ut h o r s f eel
t h a t t h e v i s i b l e - wa v e l e ngt h l a s e r s t h e a r go n a n d t h e
KT P - 5 3 2 a r e b e s t s ui t e d for o t o l o gi c wo r k.
T h e s e v i s i b l e - wa v e l e ngt h l a s e r s a r e mo s t us e f ul
f or a n u mb e r of r e a s o ns :
1. T h e y a l l o w f or e ne r g y t r a ns mi s s i o n t h r o ugh
f i b e r o pt i c c a b l e s . Th e r e f o r e , no a r t i c ul a t i ng, bul ky
a r ms a r e n e e d e d a nd de l i ve r y o f t h e b e a m t o t he
i nt r i c a t e s pa c e s o f t h e mi ddl e e a r i s mo r e e a s i l y
a c c o mp l i s h e d .
2. T h e v i s i b l e - s pe c t r um l a s e r s do no t ne e d a c a r -
r i e r b e a m t o b e s e e n b y t h e na ke d e y e . Wi t h t h e CO ,
b e a m, wh i c h us e s a n i nvi s i bl e wa v e l e ng t h , a c a r r i e r
b e a m i s n e e d e d i n o r de r t o f o c us t h e b e a m o n t h e
s ur gi c a l s i t e ; i f t h e s e b e a ms a r e no t exactl y c o a xi a l , o r
i f t h e mi r r o r s o f t h e a r t i c ul a t i ng a r m a r e i mpe r f e c t l y
a l i gne d, t h e s ur gi c a l b e a m ma y no t b e de l i ve r e d
pr e c i s e l y wh e r e i t i s ne e de d.
3 . T h e v i s i b l e - wa v e l e ngt h b e a ms a r e r e a di l y a b-
s o r b e d b y pi g me nt a nd no t b y c l e a r f l ui ds , s o h e mo -
s t a s i s c a n b e a c c o mp l i s h e d .
4. Al o n g wi t h f i be r o pt i c c a pa b i l i t y a n u mb e r o f
h a n d pi e c e s h a v e b e e n de v e l o pe d, a l l o wi ng t h e b e a m
t o be de l i ve r e d by a n a l t e r na t e me t h o d . Th e h a nd
pi e c e i s h e l d l i ke a s c a l pe l , a n d t h e b e a m i s f o c us e d
by mo v i n g i t up a nd do wn.
T h e d e v e l o p me n t o f t h e l a s e r i n o t o l o gi c s ur g e r y
h a s b e e n a r e ma r ka b l e a dv a nc e ; l i ke a ny s ur g i c i !
t ool , h o we v e r , i t mus t b e us e d c o r r e c t l y . Un d e r s t a n d
i ng t h e l a s e r i s a b s o l ut e l y e s s e nt i a l , a nd p r o p e -
t r a i ni ng t h r o ugh a " h a n d s - o n " c o ur s e i s n e c e s s a r
b e f o r e o n e c a n e f f i c i e nt l y a nd s a f e l y us e t h i s ne v
t ool .
I n di s c us s i ng t h e s ur gi c a l a ppl i c a t i o ns o f t h e l a s e r
t h r e e t e r ms mus t be de f i ne d: power , spot size, anc
pulse duration. T h e p o we r of t h e b e a m i s its e ne r gy
o ut put a n d i s me a s u r e d i n wa t t s . S po t s i ze r e f e r s t' /
t h e di a me t e r o f t h e b e a m, a nd c a n v a r y f r om mi c r o ns
t o mi l l i me t e r s . P ul s e dur a t i o n i s t h e a mo u n t o f t i mi
i n wh i c h t h e b e a m a c t i ve l y pe r f o r ms i t s s ur gi c c
f unc t i o n; i t ma y be me a s ur e d i n mi l l i s e c o nds or i
ma y be c o nt i nuo us . Al l of t h e s e f unc t i o ns c a n b>
va r i e d a t a ny t i me f or di f f e r e nt s ur gi c a l ne e ds .
P o we r de ns i t y i s a no t h e r c o nc e pt t ha t mus t b-
unde r s t o o d. I t i s de f i ne d a s t h e po we r pe r un:
v o l ume ( Fi g. 1 4 - 1 / 1 ) . T h e p o we r o f t h e l a s e r b e a m i
c o ns t a nt , but by v a r y i ng t h e s po t s i ze o f t h e b e a m a
t h e f ocal poi nt , t h e p o we r de ns i t y c a n be s i gni f i c a nt ! "
a l t e r e d. F o c us i ng t h e b e a m t o a ve r y s ma l l s po t s i z
r
:
gr e a t l y i nc r e a s e s t h e p o we r de ns i t y ; wi t h a l a r ge s po*
s i ze t h e p o we r de ns i t y i s de c r e a s e d. T h i s i s a c r uc i a '
c o nc e pt i n l a s e r s ur g e r y a nd i s vi t al i n u n d e r s t a n d s ; ,
t h e s ur gi c a l r a mi f i c a t i o ns o f t h e l a s e r .
T h e s ur gi c a l e f f e c t s o f t h e l a s e r b e a m a r e t i s s ue
c ut t i ng, t i s s ue c o a gul a t i o n, a nd t i s s ue v a po r i za t i o n
( Fi g. 14I S ) . T h e y c a n be a c h i e v e d by ma ni pul a t i ng
t h e s po t s i ze o f t h e b e a m a nd v a r y i ng t h e po we r .
Cut t i ng o f t i s s ue r e qui r e s t h e h i gh e s t p o we r de ns i t y ,
s o a v e r y s ma l l s po t s i ze a nd l a r ge a mo u n t s o f p o we r
a r e us e d. Fo r v a po r i za t i o n o f t i s s ue , ful l p o we r i ;
us e d wi t h a l a r ge r s po t s i ze ; t h e de pt h of v a po r i za t i o n
c a n be c o nt r o l l e d. Co a gul a t i o n r e qui r e s a l a r ge s po t
La s e r s i n Ot o l o g i c S ur g e r y 2 73
. Power
Power density =
Spot size
CUTTING VAPORIZATION COAGULATION
Small spol Large spol Large spol
HiQh power High power Low power
FIGURE 14-1.
s i ze a n d a l o w p o we r s e t t i ng. Co a g ul a t i o n o f v e s s e l s
c a n o nl y b e a c c o mp l i s h e d wi t h v i s i b l e - wa v e l e ngt h
l a s e r s ( a r go n a nd KT P - 5 3 2 ) a n d no t wi t h t h e C 0 2
l a s e r .
Ac t ua l ma ni pul a t i o n o f t h e b e a m i s d o n e b y t he
s ur g e o n. T h e s po t s i ze c a n b e a l t e r e d i n t wo wa y s .
Wi t h t h e b e a m de l i ve r y de v i c e a t t a c h e d di r e c t l y t o
t h e mi c r o s c o pe , t h e s po t s i ze i s c h a n g e d by a r h e o -
s t a t - t y pe de v i c e o n t h e mi c r o s c o pe ; wh i l e di r e c t l y
v i s ua l i zi ng t h e b e a m, t h e s ur g e o n c a n v a r y t h e di -
a me t e r o f t h e b e a m a s n e e d e d . T h e h a nd- h e l d de l i v-
e r y s y s t e m f o c us e s a s t h e h a nd pi e c e i s mo v e d up
a nd d o wn wh i l e t h e b e a m i s wa t c h e d a t t h e s ur gi c a l
s i t e . P ul s e dur a t i o n a n d p o we r a r e s e t o n t h e ma c h i ne
i t s e l f or by a r e mo t e c o nt r o l a t t h e o pe r a t i ng t a bl e .
T h e b e a m i s a c t i va t e d by a f oot pe da l .
Laser Stapedotomy
Th i s s e c t i o n de s c r i b e s a ppl i c a t i o ns o f t h e l a s e r i n
t h e mi ddl e e a r , but t h e pr i nc i pl e s a nd t e c h ni que s
a l s o a ppl y t o ma s t o i d wo r k. S pe c i f i c a p p r o a c h e s t o
t h e s ur gi c a l s i t e ( i nc i s i o ns , f l a ps , a nd s o o n) h a v e
b e e n de s c r i b e d e l s e wh e r e . T h e di s c us s i o n wi l l f oc us
2 74 La s e r s i n Ot o l o gi c S ur g e r y
o nl y o n l a s e r a ppl i c a t i o ns t o t i s s ue s ; a ny s pe c i f i c
a p p r o a c h e s t h a t a r e c a l l e d f or a r e e x pl a i ne d.
Highlights
1. G o o d l ocal a ne s t h e s i a
2 . Co o d h e mo s t a s i s .
3 . Re mo v a l o f t he s c ut um.
4 . Kn o wl e d g e a b l e nur s i ng a s s i s t a nt s
5. S upe r i o r i ns t r ume nt a t i o n
6. Us e of a s t a pe s h o l de r .
7. P r e s e r v a t i o n o f t h e c h o r da t y mpa ni .
8. Vi s ua l i za t i o n o f t h e py r a mi da l pr o c e s s a nd t he
f aci al ne r v e .
9 . Un d e r s t a n d i n g o f l a s e r t e c h ni que s a nd us e .
10. Co mp l e t e vi s ua l i za t i o n o f t h e o s s i c l e s .
Pitfalls
1. F o r mi n g b l e b s i n t h e e x t e r na l a udi t o r y c a na l
wh i l e i nj e c t i ng
2 . Te a r i ng t h e t y mpa ni c me mb r a n e dur i ng e l e va -
t i on.
3 . I na de qua t e e x po s ur e .
4 . Te a r i ng t h e c h o r da t y mpa ni .
5. I ne x pe r i e nc e d s c r ub nur s e .
6. I nj ur i ng t h e facial ne r v e .
7. P l a c i ng t he pr o s t h e s i s t oo de e p i n t he ova l
wi n d o w.
Procedure
T h e l a s e r s t a pe do t o mv i s a ve r v s uc c e s s f ul a nd
e f f i c i e nt pr o c e dur e . Ini t i al l y t he e a r i s pr e pa r e d a nd
dr a pe d i n t h e us ua l f a s h i o n. Al l s t a pe do t o mi e s ar e
d o n e un d e r l oc a l a ne s t h e s i a ; t h e a ut h o r s us e 2 %
l i do c a i ne wi t h 1: 20, 000 e pi ne ph r i ne . A s t a nda r d f our -
qua dr a nt i nj e c t i o n i s ma d e wi t h a 2 7 - g a ug e ne e dl e .
T h e e a r i s t h e n i r r i ga t e d wi t h po v i do ne - i o di ne ( Be -
t a di ne ) t h r o ugh a b ul b s y r i nge .
A s t a nda r d s t a pe s f l ap i s e l e v a t e d wi t h a r o und
kni f e . A s e mi c i r c ul a r i nc i s i o n i s ma d e s t a r t i ng at t he
6 o ' c l o c k po s i t i o n, t r a ve l i ng up t h e po s t e r i o r c a na l
wal l , a nd e n d i n g a t t h e 12 o ' c l o c k po s i t i o n j us t a b o v e
t h e s h o r t pr o c e s s o f t h e ma l l e us . T h e f l ap i s e l e va t e d
t o t h e a n n ul us a nd t h e mi ddl e e a r i s e nt e r e d i n t he
us ua l f a s h i o n. T h e c h o r da t y mpa ni ne r v e i s i de nt i f i e d
a nd pr e s e r v e d
T h e s t a pe s f l ap i s r ot a t e d a nt e r i o r l y unt i l t h j
po s t e r i o r b o r de r o f t h e ma l l e us i s di r e c t l y vi s ua l i ze d
T h e b o n y s c ut um i s t h e n r e mo v e d unt i l t h e f aci al
ne r v e i s vi s ua l i ze d a b o v e t h e s t a pe s a nd t h e py r a m-
i dal pr o c e s s of t h e s t a pe di a l t e ndo n i s i de nt i f i e d
po s t e r i o r l y . I t i s v e r y i mpo r t a nt t o vi s ua l i ze t h e i r
t wo s t r uc t ur e s t o e ns ur e a de qua t e wo r ki ng r o o m.
Ma ni pul a t i o n o f t h e ma l l e us a nd i nc us i s t h e i .
d o n e t o r ul e o ut f i xa t i on of e i t h e r s t r uc t ur e a s t h
c a us e of t h e c o nduc t i v e h e a r i ng l o s s . At t e nt i o n I
n o w f o c us e d o n t h e s t a pe s ; a ga i n, ma ni pul a t i o n wi Mi
a s ma l l r i gh t - a ngl e d h o o k i s d o n e t o c o nf i r m f i xa t i on
T h e i nc us - s t a pe s j o i nt i s s e pa r a t e d. T h e s t a pe s hol d, ?
i s t h e n b r o ugh t i nt o t h e f i el d.
Wi t h a dj us t me nt o f t h e l a s e r s po t s i ze a nd b e a -
pa r a me t e r s d o n e pr e o pe r a t i v e l y , t h e a c t ua l l a s e i
wo r k b e gi ns . T h e s t a pe di a l t e ndo n i s f o c us e d o n a n c
v a po r i ze d, us i ng t h e l a s e r a t 2 . 0 wa t t s o f p o we r a r o
a pul s e d b e a m o f 0.;1 s e c o nd. T h e b e a m i s s h a r p' ;
f o c us e d o n t h e t e n d o n b y a " j o y s t i c k" mo u n t e d c r
t h e mi c r o s c o pe , a n d i s f i r ed by a f oot c o nt r o l wh e n
t h e o pe r a t o r i s r e a dy . T h e s mo k e pl ume i s dr a wr
a wa y by a No . 22 s uc t i o n tip h e l d i n t h e o pe r a t o r ?
l eft h a nd ( Fi g. 1 4 - 2 A) .
O n c e t h e t e ndo n h a s b e e n v a po r i z e d, a me a s u r e
me n t i s t a ke n f r om t h e l at er al s ur f a c e of t h e i nc us ::
t h e f o o t pl a t e o f t h e s t a pe s . Ad d i n g 0. 5 mm t o t h s
me a s u r e me n t gi v e s t h e pr o pe r l e ngt h f or t h e pr o: -
t h e s i s . Th i s l e ngt h wi l l va r y wi t h t he t y pe o f p r e -
t h e s i s , poi nt o f me a s u r e me n t , a n d o t h e r f a c t o r s . Th - '
l a s e r b e a m i s t h e n f o c us e d on t h e po s t e r i o r c r us t i
t h e s t a pe s Aga i n, wi t h a pul s e d b e a m a nd ( h e s a m
po we r s e t t i ngs , t h e c r us i s l a s e d a wa y ( Fi g. 1 4 - 2 8 ) .
T wo s ug g e s t i o ns ma y b e h e l pf ul a t t hi s s t a ge :
1. If t h e h e me i s v e r y wh i t e , v a po r i za t i o n ma y r>.
s l o w b e c a us e t h e b e a m i s a b s o r b e d b v pi g me nt . / .
dr o p o f b l o o d, b o n e c h a r , o r e v e n ge nt i a n vi ol e t wi l l
h e l p gr e. i t l v. O n c e t he i ni t i al da r k h o nv c h a r de v e l
o ps . v a po r i za t i o n pr o c e e ds ve r v qui c kl v.
2 . Wh e n e x c e s s c h a r bui l ds up a r o und t h e b o n e
v a po r i za t i o n ma y a ga i n b e s l o w. T h e c h a r s h o ul d b i
ge nt l y c h i ppe d a wa y wi t h a s ma l l r i gh t - a ngl e d pi c k
O n c e t h e po s t e r i o r c r us h a s b e e n v a po r i z e d, th*
a nt e r i o r c r us i s a ddr e s s e d. Of t e n i t c a n be s e e i
di r e c t l y a nd r e mo v e d i n t h e s a me wa y a s t h e po s t e
r i or c r us . Wh e n t h e a nt e r i o r c r us c a nno t b e di r e c t l y
vi s ua l i ze d b e c a us e o f t h e b o dy o f t h e I nc us , a s pe
ci al l y de s i g ne d mi r r o r i s n e e d e d t o r ef l ect t h e b e a m
o nt o it. T h e b e a m i s first f o c us e d o n t h e p r o mo n t o r v
j us t a nt e r i o r t o t h e a nt e r i o r c r us . T h e mi r r o r i s
i nt r o duc e d unt i l t h e a nt e r i o r c r us i s r e f l e c t e d. T h e
b e a m i s t h e n b o un c e d of f t h e mi r r o r o nt o t h e a nt e r i o' "
c r us unt i l i t i s v a po r i ze d ( Fi g. 1 4 - 2 C) .
At t e nt i o n i s t h e n t ur ne d t o t h e f o o t pl a t e o f t he
s t a pe s . T h e a ut h o r s us e e i t h e r a 0. 8 - mm or a 0. 6 - mm
La s e r s i n Ot o l o gi c S ur g e r y 2 75
FIGURE 14-2.
276 La s e r s i n Ot o l o g i c S ur g e r y
Laser Applications
in the Middle Ear
I ni t i a l l y r e s t r i c t e d t o s t a p e d o t o my pr o c e dur e s , us e
o f t h e l a s e r h a s b e e n e x p a n d e d t o i nc l ude e v e r y c a s e
i n t h e a ut h o r s ' o t o l o gi c pr a c t i c e . I t h a s pr o v e d t o be
e x t r e me l y us e f ul i n r e c o ns t r uc t i o n a nd c h o l e s t e a t o ma
wo r k i n t h e mi ddl e e a r a nd ma s t o i d.
Ossicles
T h e l a s e r h a s b e e n ve r y be ne f i c i a l i n wo r k a r o u n d
t h e o s s i c l e s . S i nc e ma ni pul a t i o n o f t h e o s s i c l e s a nd
c o r r e s po ndi ng t r a uma po t e nt i a l l y ma y c a us e s e n s o -
r i ne ur a l h e a r i ng l o s s a nd o s s i c ul a r di s a r t i c ul a t i o n, i *
i s de s i r a b l e t o mi ni mi z e t h i s ma ni pul a t i o n. T h e
h i gh l y f o c us e d b e a m o f t h e l a s e r c a n vi r t ua l l y e l i mi -
na t e ma nua l t r a uma i nv o l v i ng t h e o s s i c l e s .
T h e l a s e r i s e s pe c i a l l y us e f ul i n t h e p r e s e n c e o f
c h o l e s t e a t o ma o r a dh e s i o ns a r o un d t h e s t a pe s o r i r
t he ova l wi n d o w ni c h e . Wi t h v e r y a dh e r e nt di s e a s e
di s a r t i c ul a t i o n wi t h r e s ul t a nt pe r i l y mph l e a k i s a t
wa y s a h a z a r d. Us i ng a f i ne l y f o c us e d b e a m of s h o r t
pul s e dur a t i o n ( 0. 1 t o 0. 3 s e c o nds ) a nd l o w p o we r ( i
t o 3 wa t t s ) , di s e a s e c a n be v a po r i z e d wi t h o ut t r a uma
t o t h e ne a r b y o s s i c l e s .
An o t h e r us e f or t h e l a s e r i s i n t h e e a r f i l l ed wi t h
a dh e s i o ns a nd po l y po i d ma t e r i a l . S e t t i ng t h e b e a m
f or c o a gul a t i o n pa r a me t e r s , s ur f a c e c o a gul a t i o n o f
t h e s e s ma l l v e s s e l s c a n b e a c c o mpl i s h e d. El i mi na t i ng
or r e duc i ng t h i s nui s a nc e b l e e di ng pe r mi t s a s a f e r
a nd f a s t e r pr o c e dur e . I n a ddi t i o n, v a po r i za t i o n o f
t h e a d h e s i o n s c a n b e a c c o mp l i s h e d wi t h a dj us t me nt
o f t h e b e a m pa r a me t e r s . Aga i n, t h i s e l i mi na t e s mu c h
o f t h e vi br a t o r y t r a uma , r e duc e s b l e e di ng, a nd a l l o ws
t h e s ur ge o n t o r e mo v e t h e a d h e s i o n s l a y e r b y l a y e r
( Fi g. 1 4 3 8 ) . Th i s pr e c i s i o n, e s pe c i a l l y i n t h e d e p t h s
o f t h e o va l wi n d o w wi t h di s e a s e a r o un d t h e s t a pe s
gr e a t l y e n h a n c e s t h e a bi l i t y t o r e mo v e t i s s ue wi t h o u
t r a uma t o t he s ur r o undi ng no r ma l a na t o mi c s t r uc
t ur e s .
Ano t h e r i deal s i t ua t i o n for Li - . l t wo r k i s e r o s i o r
o f t h e l e nt i c ul a r pr o c e s s o f t h e i nc us . Al t h o ug h
e r o de d a nd l a c ki ng a b o ny c o nne c t i o n wi t h the
s t a pe s , t h e l e nt i c ul a r pr o c e s s of t e n h a s e n o u g h bo nt
l eft t o ma k e r e c o ns t r uc t i o n di f f i cul t . Us i ng t h e l a s e r
t h e s ur ge o n c a n v a po r i ze t h e b o n e qui c kl y , s h a r pl y ,
a nd a t r a uma t i c a l l y t o a l l o w mo r e r o o m ( or t h e r e c on-
s t r uc t i ve pr o c e dur e ( Fi g. 1 4 - 3 / 1 ) .
T h e l a s e r a l s o i s qui t e us e f ul i n t y mpa ni c me m-
b r a ne wo r k. F r e s h e ni ng t h e e d g e s o f a pe r f o r a t i o n i r
pr e pa r a t i o n f or a gr af t c a n be d o n e e a s i l y a nd qui c kl y .
A pul s e d o r c o nt i nuo us b e a m f o c us e d o n t h e pe r i pl v
e r y o f t h e pe r f o r a t i o n c a n b e us e d t o r e mo v e t h f
r ol l e d e dg e s o f t h e pe r f o r a t i o n ( Fi g. 1 4 - 3 C) .
Wh e n e l e v a t i o n o f t h e pe r i o s t e um o f t h e ma l l e uc
i s r e qui r e d i n gr a f t i ng t e c h ni que s , t h e a r e a a r o und
t he u mb o i s a l wa y s ve r y a dh e r e nt . T u g g i n g a nd
pul l i ng o f t h i s t i s s ue c a us e s c o ns i de r a b l e v i b r a t o r y
t r a uma t h r o ug h o ut t h e o s s i c ul a r c h a i n. O n c e
a ga i n, t i s s ue c a n b e l a s e d a wa y wi t h o ut t r a uma ( Fi g
1 4 - 3 D ) .
La s e r s i n Ot o l o gi c S ur ge r y 2 77
FIGURE 14-3.
o p e n i n g i nt o t h e i nne r e a r ; t he f o r me r i s pr e f e r r e d
unl e s s t h e r e i s no t e n o u g h r o o m. A t e mpl a t e i s pl a c e d
o n t h e f o o t pl a t e , ma ki ng a vi s ua l i ma g e o f t he 0. 8 -
mm s i t e ( Fi g. 1 4 - 2 D ) . T h e l a s e r i s t ur ne d t o 1. 8 wa t t s
a n d a 0. 1 - s e c o n d pul s e d b e a m. A r o s e t t e pa t t e r n i s
ma d e o n t h e f o o t pl a t e , c o r r e s po ndi ng t o t h e 0. 8 - mm
s t a p e d o t o my o pe ni ng . Us ua l l y o n e pul s e wi l l o pe n
t h e f o o t pl a t e . I t i s i mpo r t a nt t o o v e r l a p t h e s e l a s e r
" h i t s , " b e c a u s e t h e c h a r f r om e a c h pr e v i o us hit wi l l
a b s o r b t h e h e a t a nd a l l o w f or be t t e r v a po r i za t i o n
T h e t e mpl a t e i s r e i nt r o duc e d t o e n s ur e t ha t t he
o p e n i n g i s t h e pr o pe r s i ze .
T h e pr o s t h e s i s i s t h e n po s i t i o ne d o v e r t h e i nc us
a nd i nt o t h e s t a p e d o t o my o p e n i n g a nd c r i mpe d i nt o
po s i t i o n ( Fi g. 142) . T h e pa r t o f t h e pr o s t h e s i s t hat
fits i nt o t h e v e s t i b ul e i s e x a c t l y 1 mm i n l e ngt h ; wh e n
pr o pe r l y po s i t i o ne d, h a l f o f it, o r 0. 5 mm, s i t s i n t he
v e s t i b ul e . S i nc e t h i s s e c t i o n o f t h e pr o s t h e s i s i s o nl y
1 mm l o ng, i t i s e a s y t o j ud g e t h e c o r r e c t de pt h .
T wo a ddi t i o na l s ug g e s t i o n s a r e r e l e v a nt h e r e ;
1. I f s o me o f t h e l a s e r h i t s do no t c a us e pe r i l y mph
t o f l ow a n d do no t e x t e nd al l t h e wa y t h r o ugh t he
f o o t pl a t e b o n e , t h i s i s no t c a us e f or a l a r m. I f mo s t o f
t h e h i t s go t h r o ugh t h e b o ne , t h e pr o s t h e s i s wi l l
e a s i l y b r e a k t h r o ug h t h e r e ma i ni ng o n e s
2. S o me t i me s a s ma l l a mo u n t of r e s i dua l c h a r
f r o m t h e v a po r i za t i o n i s l eft on t h e f o o t pl a t e . I t i s
no t ne c e s s a r y t o r e mo v e t h i s .
O n c e t h e pr o s t h e s i s i s c o r r e c t l y po s i t i o ne d a nd
c r i mp e d , t h e t y mpa ni c me mb r a n e i s r e po s i t i o ne d.
Al l s o u n d i n t h e o pe r a t i ng s ui t e ( mo ni t o r s , f a ns ,
l a s e r s , a nd s o o n ) i s r e duc e d, a nd t h e pa t i e nt i s a s ke d
t o c o unt n u mb e r s t o o bt a i n a s ub j e c t i v e h e a r i ng l e ve l .
Wh e n t h e s ur g e o n i s s a t i s f i e d wi t h t h e h e a r i ng l e ve l ,
t h e f o o t pl a t e i s r e vi s ua l i ze d. If t h e pr o s t h e s i s i s f i r ml y
f i xe d i n po s i t i o n, o n e o r t wo s ma l l dr o ps o f a ut o ge -
n o us b l o o d a r e i ns t i l l e d i n t h e o va l wi n d o w t o a c t a s
a s e a l . T h e f l ap i s t h e n r e po s i t i o ne d a nd pa c ke d wi t h
Ge l f o a m, a ma s t o i d dr e s s i ng i s pl a c e d, a nd t h e pa -
t i e nt i s t a ke n t o t h e r e c o v e r y r o o m.
2 78 La s e r s i n Ot o l o gi c S ur ge r y
As me n t i o n e d pr e v i o us l y , t h e a r go n a n d KT P - 5 3 2
l a s e r s a r e r e a di l y a b s o r b e d b y pi g me nt a n d h e mo g l o -
bi n. Be c a u s e o f t h i s a f f i ni t y, h e mo s t a s i s o f s ma l l
mi ddl e e a r cl ef t b l e e di ng c a n of t e n b e a c c o mpl i s h e d.
Wi t h a l a r ge s po t s i ze , pul s e d b e a m, a n d l o w po we r ,
nui s a nc e b l e e di ng f r om muc o s a l a r e a s c a n b e c o n-
t r ol l e d. Ag a i n, t h e s pe e d a nd pr e c i s i o n o f t h e l a s e r
i n h e mo s t a s i s l e nds i t s e l f gr e a t l y t o t h e e n h a n c e me n t
o f r e c o ns t r uc t i v e wo r k.
T h e l a s e r i s i de a l l y s ui t e d f or r e pa i r of a f i xed
ma l l e us . T h e di f f i cul t y i n dr i l l i ng a r o und t h e o s s i c l e s
I n t h e a t t i c i s gr e a t l y r e duc e d. Al s o , di s a r t i c ul a t i o n
o f t h e i nc us - s t a pe s j o i nt i s no t n e e d e d b e c a us e o f t he
a t r a uma t i c b o n e v a po r i za t i o n. A s t a nda r d po s t a ur i c -
ul ar i nc i s i o n i s ma d e a nd a n a t t i c o t o my i s pe r f o r me d
( de s c r i b e d e l s e wh e r e i n t h i s b o o k ) . Dr i l l i ng i s do ne
unt i l t h e f i xed o s s i c l e s a r e i de nt i f i e d. I n t h e a ut h o r s '
e x pe r i e nc e , t h e di f f i c ul t y l i es i n f r e e i ng t h e f i xa t i on,
wh i c h i s us ua l l y a nt e r i o r a nd me di a l t o t h e ma l l e us
a nd i nc us . I t i s e x t r e me l y di f f i cul t t o dr il l t hi s b o n e
a wa y ; c ur e t t i ng a l s o i s c r ude a n d di f f i cul t . O n c e t h e
f i xat i on i s v i s ua l i ze d, t h e l a s e r pr o v i de s a n i deal wa y
t o r e mo v e t h e b o ne wi t h o ut t r a uma t o t h e o s s i c l e s .
A pul s e d o r c o nt i nuo us b e a m s h a r pl y f o c us e d o n t h e
b o ny f i x a t i o n v a po r i z e s t h e b o ne , a l l o wi ng fr ee mo -
bi l i t y of t h e c h a i n ( Fi g. 1 4 - 3 E) . A s ma l l pi e c e of
Si l a s t i c i s t h e n i ns e r t e d b e t we e n t h e o s s i c l e s a nd t he
a r e a o f f i xa t i on t o h e l p pr e v e nt b o n e r e gr o wt h .
Summary
T h e l a s e r h a s ma r ke dl y r e duc e d t h e de g r e e o f
vi br a t o r y t r a uma t o t h e o s s i c l e s a nd t h us t o t h e i nne r
e a r f l ui ds . By mi ni mi z i ng t r a uma , t h e s ur g e o n r e-
duc e s t h e c h a n c e s o f i a t r o ge ni c s e ns o r i ne ur a l h e a r i ng
l os s . T h e pr e c i s i o n o f t he b e a m a l l o ws t h e s ur ge o n
t o r e a c h a r e a s o f t h e mi ddl e e a r cl ef t s a f e l y , qui c kl y ,
a n d wi t h l e s s po t e nt i a l for i nj ur y t o t h e pa t i e nt . A
s e c o n d ma j o r a dv a nt a g e l i es i n t h e h e mo s t a t i c pr op-
e r t i e s o f t h e v i s i b l e - s pe c t r um l a s e r . T h e c o nf i ne s o f
t he mi ddl e e a r h a v e a l wa y s b e e n di f f i cul t t o r e a c h
f or c o n v e n t i o n a l c o a gul a t i o n. T h e pi gme nt - a b s o r p-
t i ve pr o pe r t i e s o f t h e v i s i b l e - s pe c t r um b e a ms h a ve
gr e a t l y e n h a n c e d t h i s pr o c e dur e . T h e s e t wo f e a t ur e s
o f t h e l a s e r h a v e a dde d a n e w di me ns i o n t o o t o l o gi c
s ur ge r y .
Neurotology and the Laser
|:
T h e l a s e r a l s o i s us e d e x t e ns i v e l y i n ne ur o t o ! o j ; i c
pr a c t i c e , a nd h a s b e e n a n i nv a l ua b l e a ddi t i o n, t o
a c o us t i c n e u r o ma wo r k. I t i s us e d f or t h r e e f unc t i o ; s :
( 1) h e mo s t a s i s , ( 2) v a po r i za t i o n o f t h e t umo r , a n d i3)
t umo r c ut t i ng f or r e mo v a l .
Procedure
T u mo r e x p o s u r e i s a c c o mp l i s h e d b y t h e s t a nda r d
a ppr o a c h e s t o t h e po s t e r i o r a nd mi ddl e f o s s a , wh i c h
h a v e b e e n de s c r i b e d e l s e wh e r e . I n t h e t r a ns l a by r i n-
t h i ne a ppr o a c h , t h e i nt e r na l a udi t o r y c a na l b o m i s
t h i nne d o n i t s s upe r i o r , po s t e r i o r , a nd i nf e r i or bor -
de r s . O n c e t h e e ggs h e l l - t h i n b o n e i s l eft, t h e l a s e r j s
us e d i ni t i al l y f or s ur f a c e c o a gul a t i o n ( Fi g. 1 4 - 4 . " ) .
T h e a r e a o v e r t h e f aci al ne r v e i n t h e a nt e r o s upe r i >r
qua dr a nt i s c o v e r e d wi t h Co t t o no i d f or pr o t e c t i o n.
T h e l a s e r i s us e d at a ppr o x i ma t e l y 4 t o 6 wa t t s i f
po we r wi t h a pul s e d b e a m a nd a l a r ge s po t s i zr .
Be c a us e of t h e b e a m' s a f f i ni t y for pi g me nt , i t i s
a b s o r b e d by t h e h e mo g l o b i n. Co a gul a t i o n i s a c c o m-
pl i s h e d o v e r t h e s ur f a c e o f t h e t umo r a nd t h r o ugh
t h e e ggs h e l l - t h i n b o n e . S ur f a c e c o a gul a t i o n o f t he
s ma l l c a pi l l a r i e s be f o r e o p e n i n g t h e dur a o f t he
i nt e r na l a udi t o r y c a na l r e duc e s a nd s o me t i me s c o m-
pl e t e l y pr e v e nt s nui s a nc e b l e e di ng f r om s ma l l dur i l
t umo r v e s s e l s . O n c e s ur f a c e c o a gul a t i o n i s a c c o m-
pl i s h e d, t h e f aci al ne r v e i s i de nt i f i e d i n t h e i nt e r ni l
a udi t o r y c a na l . Di s s e c t i o n i s j c c o mp l i s h e d i n t he
c a na l i n t h e s t a nda r d f a s h i o n. Af t e r t h e f aci al ne ' e
i s i de nt i f i e d a nd Co t t o no i d i s pa c ke d a r o und i t -dr
pr o t e c t i o n, t h e t umo r b ul k i n t h e c a na l i s v a p o r L e c
a wa y ( Fi g. 1 4 - 4 B ) . By ma ni pul a t i ng t h e p o we r i e t
t i ngs a n d b e a m s po t s i ze , t umo r c a n b e v a po r b e c
s a f e l y a nd qui c kl y , of t e n wi t h mi ni ma l b l e e d i n g . '
S t a nda r d po s t e r i o r f os s a p r o c e d u r e s p r o t e c t ' j n
o f o t h e r c r a ni a l ne r v e s , t h e c e r e b e l l um, a nd h e
b r a i ns t e m wi t h Co t t o no i da r e f o l l o we d o n c e t un o r
r e mo v a l i n t h e a ng l e i s b e g u n . T h e f aci al ne r v e i s
a l wa y s ke pt i n v i e w but i s pr o t e c t e d wi t h Co t t o no . d
T u mo r r e mo v a l by v a po r i za t i o n i s d o n e a l mo s t e x c tt-
s i ve l y wi t h t h e l a s e r i n t h e c e r e b e l l o po nt i ne a ngl e .
T h e a ut h o r s us e ful l p o we r ( 8 t o 10 wa t t s ) wi t t a
La s e r s i n Ot o l o g i c S ur g e r y 2 79
FIGURE 14-4.
2 80 La s e r s i n Ot o l o gi c S ur ge r y
c o nt i nuo us b e a m a nd a me d i u m s po t s i ze . T u mo r
r e mo v a l i s d o n e f r om t h e i nt e r i or o f t h e t umo r ,
i ni t i al l y ke e pi ng t h e c a ps ul e i nt a c t . S uc t i o n i s us e d
t o dr a w a wa y t h e s mo k e p l u me f r om t h e v a po r i za t i o n
pr o c e s s . As i t s i nt e r i o r i s v a po r i z e d, t h e t umo r c a p-
s ul e c o l l a ps e s a n d f ur t h e r di s s e c t i o n o f t h e c a ps ul e
f r om s u r r o u n d i n g s t r uc t ur e s c a n b e a c c o mpl i s h e d.
Wi t h v e r y l a r ge t umo r s , t h e t umo r i t s e l f c a n b e c ut
a wa y wi t h t h e l a s e r . T h e b e a m pa r a me t e r s ar e
c h a n g e d t o a ve r y s h a r p f o c us wi t h ful l p o we r a nd
c o nt i nuo us dur a t i o n. Us i ng t h i s b e a m, t umo r bul k i s
c ut a wa y e a s i l y wi t h mi ni ma l b l e e di ng ( Fi g. 1 4 - 4 C) .
T h e t e c h ni que s a nd us e s o f t h e l a s e r i n t h e s ub -
oc c i pi t a l a ppr o a c h a r e s i mi l a r . An a ddi t i o na l s t e p i s
t ha t t he dur a o v e r t h e po s t e r i o r l ip o f t h e i nt e r na l
a udi t o r y c a na l i s l a s e d a wa y ; a ga i n, i t c a n be r e mo v e d
qui c kl y a nd wi t h o ut b l e e di ng, a nd l e s s t i me i s ne e de d
for bi po l a r c a ut e r y or dr i l l i ng.
S e c t i o ni ng o f t h e v e s t i b ul a r ne r v e c a n a l s o b e do ne
wi t h t h e l a s e r . T h e ne r v e i s i s o l a t e d by s t a nda r d
t e c h ni que s , a nd t h e c o c h l e a r a nd f aci al ne r v e s a r e
pr o t e c t e d wi t h Co t t o no i d; t h e v e s t i b ul a r ne r v e i s t h e t
v a po r i ze d a wa y . I n t h i s c a s e , h o we v e r , t h e a ut h o r a
feel t ha t c o nv e nt i o na l s e c t i o ni ng wi t h s c i s s o r s i s j u t
a s e f f e c t i ve .
Va s c ul a r l e s i o ns , e s pe c i a l l y s ma l l g l o mu s t y mp a r -
i c um t umo r s , a l s o c a n b e de b ul ke d wi t h t h e l a s e : .
S ma l l f e e de r v e s s e l s a r e e a s i l y c o a gul a t e d wi t h th";
v i s i b l e - s pe c t r um b e a m. T h e c a ps ul e o f t h e t umo r ;
c a ut e r i ze d wi t h l o w po we r s e t t i ngs a nd a di f f us e d
b e a m. Th i s us e o f t h e l a s e r " t o u g h e n s " t h e c a ps ul e
a l l o wi ng f or e a s i e r a nd s a f e r ma ni pul a t i o n o f t h' i
t umo r . La r ge v e s s e l s c a nno t b e c o a gul a t e d wi t h t h r
b e a m, b ut by r e duc i ng t h e f e e de r v e s s e l s , t u mo
r e mo v a l i s f a c i l i t a t e d.
I n s u mma r y , t h e l a s e r h a s pr o v e d t o be a n i nv a !
ua b l e t ool i n o t o l o gi c a nd ne ur o t o l o gi c wo r k. S t a m
da r d t e c h ni que s a r e gr e a t l y f a c i l i t a t e d by t h e l a s e r ; i f
i s pr e c i s e , f ast , s a f e , a nd v e r y e f f i c i e nt , a n d wB
pr o b a b l y b e c o me s t a nda r d i n t h e ne a r f ut ur e . T h t
ne xt h ur dl e i n o t o l o gy i s t h e i nne r e a r , a nd t h e l a s
ma y be o f be ne f i t i n t h e no t t o o di s t a nt f ut ur e .
CHAPTER 15
Surgical Approach
for
Bone Conduction
Hearing Devices
Bo n e c o nduc t i o n h e a r i ng de v i c e s a r e i n a n e a r l y
ph a s e o f d e v e l o p me n t , b ut a fir st ge ne r a t i o n i s n o w
a va i l a bl e f or c l i ni c a l us e . Th i s a r e a o f o t o l o gy s h o ul d
wi t ne s s s i gni f i c a nt po s i t i ve c h a n g e s i n f ut ur e y e a r s .
Co n d u c t o r s a r e a v a i l a b l e i n t wo t y pe s , pe r c ut a -
n e o u s a n d t r a ns c ut a ne o us . Th i s c h a pt e r de s c r i b e s
t h e s ur gi c a l t e c h ni que ( Ho u g h ' s t e c h ni que ) f or i m-
pl a nt a t i o n o f t h e Xo me d a udi a nt b o n e c o nduc t o r .
Th i s b o n e c o n d u c t o r i s a t r a ns c ut a ne o us de v i c e
c o ns i s t i ng o f a n e x t e r na l a nd a n i nt e r na l c o mp o n e n t .
Ex t e r na l l y ( o ut s i de t h e pa t i e nt ) , a mi c r o p h o n e r e-
c e i v e s s o u n d a nd c h a n n e l s i t t o a s o u n d pr o c e s s o r ;
t hi s di r e c t s a n a mpl i f i e d s i gna l a c r o s s t h e s ki n t o t h e
i mpl a nt ( t h e i nt e r na l c o mp o n e n t ) , wh i c h i s s c r e we d
i nt o t h e s kul l . T h e a mpl i f i e d s i gna l i s t r a ns mi t t e d b y
s kul t vi br a t i o n i nt o t h e i nne r e a r a n d s o und i s pe r -
c e i v e d. T h e e x t e r na l a nd i nt e r na l pa r t s o f t h e de v i c e
ar e h e l d t o ge t h e r e l e c t r o ma gne t i c a l l y . T h e s y s t e m i s
ba t t e r y o pe r a t e d.
Th i s de v i c e c ur r e nt l y i s us e d i n pa t i e nt s wi t h
e x t e r na l o r mi ddl e e a r i mpa i r me nt s wi t h g o o d b o n e
c o nduc t i o n a nd s p e e c h di s c r i mi na t i o n wh o c a nno t
be ne f i t f r o m c o nv e nt i o na l h e a r i ng a i ds ( o wi ng t o
c o nge ni t a l ma l f o r ma t i o ns , c h r o ni c e x t e r na l ot i t i s o r
o t h e r f a c t o r s ) . I ndi c a t i o ns for t h e de v i c e wi l l be
e x p a n d e d . S o me b a s i c i ns t r ume nt s ( Xo me d ki t ) a r e
r e qui r e d i n o r de r t o po s i t i o n t he i nt e r na l r e c e i v e r i n
t h e s kul l ; t h e y a r e s h o wn i n Fi gur e 1 5 - 1 .
Aim
To e x po s e i a s i t e i n t h e a r e a o f t h e l i ne a t e mpo r a l i s
f or s a f e pl a c e me nt o f t h e r e c e i ve r , wh i l e a l l o wi ng
a de qua t e s ki n c o v e r a g e a n d a po s i t i o n f or t h e e xt e r na l
de v i c e t h a t i s c o mf o r t a b l e a n d h a r ml e s s .
Procedure
Af t e r pr e pa r a t i o n a nd s h a v i ng o f t h e po s t a ur i c ul a r
a r e a , t h e e a r i s s t e r i l e l y dr a pe d. A po s t a ur i c ul a r l i ne
i s t r a c e d h o r i zo nt a l l y at a l e ve l i mme di a t e l y s upe r i o r
t o t h e t r a gus . T h e r e c e i v e r ( i mpl a nt ) i s t o be pl a c e d
b e h i nd t h e po s t e r i o r e dg e o f t h e pi nna . Appr o x i -
ma t e l y 1 5 t o 1 8 mm f r o m t h i s po s t e r i o r e dg e a nd
i mme di a t e l y a b o v e t h e h o r i zo nt a l l i ne , t h e b ur h o l e
t e mpl a t e i s po s i t i o ne d a n d t h e s i t e o f t h e r e c e i ve r
de l i ne a t e d ( Fi g, 1 5 - 2 4 ) .
An i nc i s i o n s i t e i s t r a c e d a t l e a s t 1 c m po s t e r i o r t o
t h e e dg e o f t h e r e c e i v e r a n d i nj e c t e d wi t h 2 % l i do-
c a i ne ( Xy l o c a i ne ) wi t h 1 : 1 00, 000 e pi ne ph r i ne . T h e
i nc i s i o n i s d e e p e n e d d o wn t o t h e pe r i o s t e um, a f l ap
i s e l e v a t e d, a nd t h e l i ne a t e mpo r a l i s i s i de nt i f i e d. I f
t h e s u b c u t a n e o u s t i s s ue s a r e t h i c k, t h e a r e a t ha t wil l
283 Surgical Approach for Bone Conduction Hearing Devices
TIghtening tool
Deplh SlOp burs
Implant
Spanner attachment Full tap
Guide cylinder
Template
Universal wrenell handle
Surgical Approach for Bone Conduction Hearing Devices 282
fiGURE 15-1
FIGURE 15-2.
FIGURE 15-3.
S ur gi c a l Appr o a c h f or Bo n e Co n d uc t i o n He a r i ng De v i c e s 285
c o v e r t h e r e c e i ve r i s t h i nne d i n o r de r t o pe r mi t
a de qua t e t r a ns c ut a ne o us t r a ns mi s s i o n a nd ma g ne t i c
c o upl i ng b e t we e n t h e e x t e r na l a nd i nt e r na l de v i c e s .
T h e a r e a wh e r e t h e r e c e i ve r wi l l b e pl a c e d i s
r e i de nt i f i e d, ma r ke d, a nd e v e n e d wi t h a b ur kit
wi t h o ut dr i l l i ng d e e p i nt o t h e b o n e ( Fi g. 1 5 - 2 B ) .
( Th i s a r e a ne e ds de pt h t o r e c e i ve t h e s c r e w o f t h e
i mpl a nt . )
Us i ng t h e l a r ge r b ur i n t h e kit ( t h e bur s h a v e a
de pt h s t o p) , t he c e nt e r h o l e i s dr i l l e d ( Fi g. 1 5 - 2 C) . I f
a c e r e b r o s pi na l f l ui d l e a k o c c ur s , t h e s i t e i s s e a l e d
wi t h b o n e wa x a nd a n a dj a c e nt s i t e i s us e d.
Us i ng t h e s ma l l b ur i n t h e s et a nd t h e b ur h o l e
t e mpl a t e a s a gui de , t h r e e s ma l l c o nt r o l h o l e s a r e
dr i l l e d ( Fi g. 1 5 - 2 D ) . T h e l a r ge r c e nt r a l h o l e i s de s -
t i ne d f or t h e c e nt r a l s c r e w o f t h e i mpl a nt . T h e t h r e e
a dj a c e nt c o nt r o l h o l e s wi l l r e c e i v e t h e t h r e e pe g s o f
t he gui de c y l i nde r a n d i mpa r t s t a bi l i t y t o it.
T h e ne x t s t e p i s t o de v e l o p a t h r e a d i n t h e c e nt e r
h o l e f or t h e s c r e w o f t h e i mpl a nt . Th i s i s d o n e i n
t wo s t a g e s , us i ng t h e " h a l f t a p" a nd "f ul l t a p"
i ns t r ume nt s .
T h e g ui de c y l i nde r i s pl a c e d upr i gh t . T h e t h r e e
pe gs a r e i ns e r t e d i n t h e c o r r e s po ndi ng t h r e e h o l e s t o
ke e p t h e c y l i nde r pe r pe ndi c ul a r t o t h e b o n e s ur f a c e .
T h e fir st t a p t o be us e d i s t h e h a l f t a p; t h i s i s
t i gh t e ne d t o t h e uni v e r s a l wr e n c h h a ndl e wi t h t h e
t i gh t e ni ng t o o l . T h e uni v e r s a l wr e n c h ( wi t h t h e h a l f
t ap t i gh t e ne d t o it) i s t h e n sl i d t h r o ug h t h e gui de
c y l i nde r a nd r o t a t e d c l o c kwi s e , f i r ml y pr e s s i ng
a ga i ns t t h e s kul l . Ro t a t i o n c o nt i nue s f or % of a t ur n,
unt i l t h e g a p b e t we e n t h e wr e nc h h a ndl e a nd gui de
c y l i nde r i s c l o s e d.
T h e h a l f t a p i s r e mo v e d f r om t h e s kul l , t h e n
l o o s e ne d a nd r e mo v e d f r om t h e uni v e r s a l wr e nc h .
T h e full t a p i s n o w t i gh t e ne d t o t h e uni v e r s a l wr e n c h ,
sl i d t h r o ugh t h e gui de c y l i nde r , a nd pl a c e d o v e r t h e
c e nt e r of t h e s c r e w h o l e . Fi r s t , i t i s ge nt l y t ur ne d '/2-
t ur n c o unt e r c l o c kwi s e (in o r de r not t o a l t e r t he t h r e a d
pr e v i o us l y ma d e b y t h e h a l f t a p) *nd t h e n c l o c kwi s e
unt i l t h e g a p b e t we e n t h e wr e n c h h a ndl e a n d gui de
c y l i nde r i s c l o s e d. T h e ful l t a p i s t h e n r e mo v e d f r om
t he s c r e w h o l e . T h e t h r e a d i n t h e c e nt e r h o l e i s n o w
r e a dy f or t h e s c r e w o f t h e i mpl a nt .
T h e ful l t a p i s r e mo v e d f r om t h e uni v e r s a l wr e nc h
h a ndl e a nd r e pl a c e d wi t h t h e s pa nne r a t t a c h me nt ,
wh i c h i s de s i g ne d t o h o l d t h e i mpl a nt b o t h me c h a n -
i cal l y a n d e l e c t r o ma gne t i c a l l y . T h e i mpl a nt i s pl a c e d
i n t h e s p a n n e r a nd i ns e r t e d t h r o ugh t h e gui de c yl -
i nde r unt i l i t f a c e s t h e c e nt e r h o l e ( Fi g. 1 5 ^ 3 4 ) . T h e
i mpl a nt ( wi t h t h e s c r e w f a c i ng t h e h o l e ) i s ge nt l y
t ur ne d ' / i - t ur n c o unt e r c l o c kwi s e ( a ga i n, i n o r de r no t
t o a l t e r t h e t h r e a d i n t h e h o l e ) , a n d t h e n c l o c kwi s e
unt i l t h e g a p b e t we e n t h e wr e n c h h a ndl e a nd gui de
c y l i nde r i s c l o s e d a nd t h e r e i s a f e e l i ng of r e s i s t a nc e
( Fi g. 1 5 - 3 B ) . T h e wr e n c h a n d t h e gui de c y l i nde r a r e
r e mo v e d . T h e i mpl a nt i s ge nt l y c h e c ke d f or t i gh t ne s s
( Fi g. 1 5 - 3 C) . T h e f l ap i s r e po s i t i o ne d, t h e i nc i s i o n i s
c l o s e d i n l a y e r s wi t h a ppr o pr i a t e s ut ur e s , a nd a
ma s t o i d dr e s s i ng i s a ppl i e d.
Te s t i ng a nd us e o f t h e e x t e r na l de v i c e b e g i ns a t 8
t o 12 we e k s , d e p e n d i n g u p o n t h e h e a l i ng pr o c e s s .
Complications
Th i s i s a s i mpl e pr o c e dur e i n t e r ms of s ur gi c a l
t r a uma ; i t c a n be d o n e un d e r l ocal a ne s t h e s i a a nd
h a s f e w c o mpl i c a t i o ns . Ot h e r t h a n t h o s e i nh e r e nt i n
r a i s i ng a po s t a ur i c ul a r f l ap ( di s c us s e d e l s e wh e r e ) ,
t he ma i n po t e nt i a l pr o b l e m i s t h a t o f c e r e b r o s pi na l
f l ui d l e a k. Bur s wi t h a " s t o p " ( s uc h a s t h o s e i n t he
kit) do no t a l l o w a de e p pe ne t r a t i o n; i f a l e a k do e s
o c c ur , s e a l i ng ; t h e o pe ni ng wi t h b o n e wa x s h o ul d
s uf f i c e . P r o ph y l a c t i c a nt i bi o t i c s c o ul d be us e f ul i n
t h e s e c a s e s . An i ni t i al h i gh do s e o f i nt r a o pe r a t i v e
i nt r a v e no us a nt i bi o t i c s i s r e c o mme n d e d . Ot h e r c o m-
pl i c a t i o ns a r e c a us e d by f a i l ur e t o f o l l o w car ef ul
s ur gi c a l t e c h ni que s .
CHAPTER 16
Surgical Approaches
for
Cochlear Implants i:
Al t h o ug h t h e r e a r e ma r k e d di f f e r e nc e s a mo n g t he
di f f e r e nt t y pe s o f c o c h l e a r i mpl a nt s , t h e b a s i c pr i n-
c i pl e s o f a nd s ur gi c a l a p p r o a c h e s f or t h e s e de v i c e s
a r e s i mi l a r . Th i s c h a pt e r wi l l de s c r i b e o nl y t h e ba s i c
s ur gi c a l a p p r o a c h e s t h a t a ppl y t o i mpl a nt s i n wi de -
s pr e a d us e .
Co c h l e a r i mpl a nt s c o ns i s t o f a n e x t e r na l a nd a n
i nt e r na l c o mp o n e n t . Ex t e r na l l y , a mi c r o p h o n e pi c ks
up t h e s o u n d s t i mul a t i o n a nd s e nds i t t o t h e s o und
pr o c e s s o r , t r a ns f o r mi ng i t i nt o a c o de d e l e c t r i c a l
s t i mul us t ha t i s c a r r i e d t o t h e i nt e r na l c o mp o n e n t .
An i nt e r na l r e c e i v e r c h a n n e l s t h i s s t i mul us t h r o ugh
o ne o r mo r e a c t i ve e l e c t r o de s t o t he c o c h l e a , f or t h e
pur po s e o f s t i mul a t i ng t h e a udi t o r y ne r v e . An "i n-
di f f e r e nt " or g r o und e l e c t r o de i s pl a c e d c l o s e t o or
a wa y f r om t h e a c t i ve e l e c t r o de ; i f t h e l a t t e r , i t i s
us ua l l y pl a c e d i n t he t e mpo r a l mus c l e . Di f f e r e nt
t y pe s o f i mpl a nt de v i c e s r e qui r e di f f e r e nt t y pe s o f
g r o und e l e c t r o de s .
T h e i nt e r na l r e c e i v e r c a n b e pl a c e d e i t h e r unde r
t he s ki n ( t r a ns c ut a ne o us s t i mul a t i o n) or wi t h a pl ug
pr o t r udi ng f r om t h e s ki n ( pe r c ut a ne o us s t i mul a t i o n) .
I n mo s t c a s e s , t h e a c t i v e e l e c t r o de i s pl a c e d o n o r
t h r o ugh t h e r o und wi n d o w o f t h e c o c h l e a . T wo
s ur gi c a l a p p r o a c h e s f or p l a c e me n t o f t h e e l e c t r o de
wi l l be de s c r i b e d.
T h r e e b a s i c a p p r o a c h e s c a n b e us e d: ( 1) t h e po s -
t e r i or t y mp a n o t o my ( f aci al r e c e s s ) ; ( 2) t he ma s t o i -
d o t o my / t y mp a n o t o my ; a nd ( 3) t h e e x t e r na l a udi t o r y
' c a na l g r o o v e . T h e a ppr o a c h vi a t h e e x t e r na l a udi t o r y
i c a na l gr o o v e h a s b e e n us e d f or s o me o f t h e St o r z-
I S a n F r a nc i s c o de v i c e s ; i t wi l l no t be de s c r i b e d i n
de t a i l . As i n t h e f aci al r e c e s s a ppr o a c h , a l a r f e
po s t a ur i c ul a r f l ap i s e l e v a t e d i n c o nt i nui t y wi t h t
L
e
s ki n o f t h e po s t e r i o r c a na l a n d t y mp a n i c membrar?I
di r e c t l y e x po s i ng t h e mi ddl e e a r c a vi t y . A g r o o v e , s
c r e a t e d i n t h e po s t e r i o r c a na l , e x t e ndi ng f r o m tte
r e gi o n o f t h e r o und wi n d o w t o t h e a nt e r i o r ma r gi i
o f t h e ma s t o i d c o r t e x . T h e g r o o v e i s c o v e r e d wi t h
c or t i c a l b o n e a n d t e mpo r a l f as ci a o r wi t h a c r y l i c b o n e
c e me nt , i n o r de r t o pr e v e nt s ki n f r om di ppi ng i nt o
t h e gr o o v e a nd c o nt a c t i ng t h e e l e c t r o de l e a d. S ur gi c ? 1
pr e pa r a t i o n a n d po s i t i o ni ng i s s i mi l a r t o t h a t f l r
ma s t o i de c t o my , e x c e pt t h a t t h e a r e a t o b e s h a v l
a nd pr e pa r e d i s mo r e e x t e ns i v e t h a n i n a r e g u ' r
ma s t o i d e c t o my . An i mpo r t a nt po i nt c o nc e r ns t h e e *
o f c a ut e r y . Wh e n t h e e l e c t r o de s a r e i n t h e s ur gi ' i i l
f i el d, t h e us e o f c a ut e r y mi gh t l e a d t o t h e t r a n s mi -
s i n o f e l e c t r i c a l c ur r e nt s i nt o t h e c o c h l e a , wi l t
po t e nt i a l l y de v a s t a t i ng e f f e c t s . J udi c i o us us e o f r i -
po l a r c a ut e r y , o r no c a ut e r y a t al l , i s i ndi c a t e d o n i ;
t h e e l e c t r o de s a r e i n t h e s ur gi c a l f i el d.
Posterior Tympanotomy
(Facial Recess)
Surgical Steps
1. P o s i t i o ni ng of t h e i nt e r na l r e c e i v e r s i t e .
2. P o s t a ur i c ul a r i nc i s i o n.
3. El e v a t i o n of a po s t a ur i c ul a r f l ap.
Sur gi c a l Ap p r o a c h e s f or Co c h l e a r I mpl a nt s 2 87
4 . R e mo v a l o f t e mpo r a l mus c l e .
5. Dr i l l i ng of a s e a t f or t h e i nt e r na l r e c e i ve r .
6 . S i mp l e ma s t o i de c t o my .
7. Op e n i n g o f t h e f aci al r e c e s s .
8 . Ex po s ur e o f t h e r o und wi n d o w.
9. P l a c e me nt o f t h e i nt e r na l r e c e i ve r .
1 0. I ns e r t i o n o f t h e e l e c t r o de vi a t h e r o und wi n-
d o w o pe ni ng .
1 1 . S e c ur i ng o f t h e i nt e r na l r e c e i ve r .
12. Cl o s ur e , pa c ki ng, a nd a ma s t o i d dr e s s i ng.
Procedure
A d u mmy e l e c t r o de i s us e d t o de t e r mi ne t h e
po s t a ur i c ul a r po s i t i o n o f t h e i nt e r na l r e c e i ve r . I t
s h o ul d b e a t o r a b o v e t h e l i ne a t e mpo r a l i s , a l l o wi ng
e n o u g h s pa c e wi t h o ut i nt e r f e r i ng wi t h t h e us e o f
e y e gl a s s e s . S o me s u r g e o n s pr e f e r t o pl a c e t h e r e-
c e i v e r mo r e i nf e r i o r l y . T h e r e c e i v e r s i t e c a n b e t r a c e d
wi t h a ma r ki ng pe n or a c i r c ul a r i mpr e s s i o n c a n be
l eft by pr e s s i ng a d u mmy r e c e i v e r a ga i ns t t h e s ki n.
I nf i l t r a t i on o f t h e po s t a ur i c ul a r i nc i s i o n s i t e i s t h e
s a me a s i n a ma s t o i de c t o my ; h o we v e r , i t i s mo r e
e x t e ns i v e b e c a us e o f t h e po s t e r i o r e x t e nt o f t h e i nc i -
s i o n. T h e i nc i s i o n i s ma d e 1 c m b e h i n d t h e o ut e r
e dg e o f t h e i nt e r na l r e c e i v e r a n d e x t e nds d o wn t o
t he l e ve l o f t h e ma s t o i d pr o c e s s wi t h o ut b e ndi ng
t o wa r d it, i n o r de r t o a v o i d c o mp r o mi s e o f t h e
o c c i pi t a l a r t e r y . T h e f l ap i s de v e l o pe d a nt e r i o r l y
b e t we e n t h e s c a l p a nd t h e t e mpo r a l mus c l e unt i l t h e
s pi ne o f He nl e i s e x p o s e d .
A pi e c e o f t e mpo r a l mus c l e o v e r t he s q u a mo u s
po r t i o n o f t h e t e mpo r a l b o n e i s r e mo v e d , a s we l l a s
t e mpo r a l f a s c i a . T h i s a l l o ws f or a n a de qua t e s e a t for
t h e r e c e i v e r , a nd f or a t h i nne r s c a l p i f a t r a ns c ut a -
ne o us de v i c e i s t o be us e d. A s e a t for*
1
t h e i nt e r na l
r e c e i v e r i s dr i l l e d ( Fi g. 16I B) . I t i s i mpo r t a nt t o do
t h i s i n a pl a ne pa r a l l e l t o t h e s c a l p s ur f a c e . Wi t h a
t r a ns c ut a ne o us de v i c e , i t i s us e f ul t o s e c ur e t h e
r e c e i v e r wi t h p e r ma n e n t s ut ur e s ( Fi g. 1 6 - 2 A , 8 ) .
Wi t h a 2 - mm pi l ot dr i l l , t wo h o l e s 2 mm a pa r t a r e
dr i l l e d o n b o t h s i de s o f t h e s e a t , a t a di s t a nc e o f 0. 5
t o 0. 7 5 c m f r o m t h e o ut e r e dg e ; a pa s s a ge b e t we e n
t he h o l e s i s ma d e wi t h a 0. 5 - mm c ut t i ng b ur a t a 3 0-
de g r e e a ngl e . F o r a pe r c ut a ne o us de v i c e , a ddi t i o na l
h o l e s c a n b e dr i l l e d f or pl a c e me nt o f s c r e ws ( Fi g. 1 6 -
2 / V) .
A s i mpl e ma s t o i d e c t o my a nd o p e n i n g o f t h e f aci al
r e c e s s i s d o n e ( Fi g. 1 6 - 1 A) ( s e e Ch a p t e r 7 ) ; t h e o nl y
di f f e r e nc e i s t h a t t h e e dg e s o f t h e c a vi t y a r e not
s a uc e r i z e d i n o r de r t o a l l o w f or a g r o o v e f or t h e
e l e c t r o de . T wo a ddi t i o na l h o l e s c a n b e dr i l l e d i n t h e
b o r de r o f t h e ma s t o i d c a vi t y f or t h e pur po s e o f
s e c ur i ng t h e e l e c t r o de a t t h i s l e ve l wi t h p e r ma n e n t
s ut ur e s .
T h e r o un d wi n d o w ni c h e i s vi s ua l i ze d t h r o ugh
t he facial r e c e s s ( Fi g. 1 6 - 2 D ) . Us i ng a s ma l l bur , t h e
a nt e r o s upe r i o r l i p o f t h e ni c h e i s r e mo v e d a nd t h e
r o und wi n d o w me mb r a n e i s b r o ugh t di r e c t l y i nt o
vi e w. I f t h e wi n d o w c a nno t b e vi s ua l i ze d, dr i l l i ng
t o wa r d t h e p r o mo n t o r y wi l l h e l p t o pr o v i de a s t r a i gh t
vi e w o f t h e ba s a l t ur n, b y pa s s i ng t h e " h o o k . " Th i s
s h o ul d be d o n e c a ut i o us l y , i n a s t e p- b y - s t e p f a s h i o n.
If b o ne g r o wt h i s pr e s e nt i n t h i s a r e a , a "s t r a i gh t
po s i t i o n" i s r e a c h e d a n d dr i l l i ng i s d o n e a nt e r i o r l y
( f o r wa r d) i nt o t h e s c a l a t y mpa ni . Th i s wi l l l e a d t o a n
o pe n s c a l a or pr o v i de a s pa c e f or pl a c i ng t h e e l e c -
t r ode .
Th e e l e c t r o de i s t h e n i nt r o duc e d a nd t h e r o und
wi n d o w ni c h e i s s e a l e d wi t h f a s c i a ( Fi g. 1 6 - 3 ) . A
no ns e r r a t e d o r s pe c i a l l y c o a t e d a l l i ga t o r f o r c e ps
s h o ul d b e us e d f or e l e c t r o de i ns e r t i o n, h e l pe d b y
bl unt wi r e gui de s o r h o e s . Ex t r e me c a r e mus t b e
us e d wh e n h a ndl i ng t h e e l e c t r o de i n o r de r t o a vo i d
da ma g i ng it. Wi t h t h e 3 M Ho u s e t y pe , o nl y t he
no ni ns ul a t e d po r t i o n i s i nt r o duc e d.
On c e t h e e l e c t r o de h a s b e e n pl a c e d, t h e i nt e r na l
r e c e i ve r i s s e c ur e d. Fo r a t r a ns c ut a ne o us de v i c e , 4- 0
sil k s ut ur e s a r e pa s s e d t h r o ugh t h e 2 - mm h o l e s
dr i l l ed a r o un d t h e s e a t ( Fi g. 1 6 - 4 / 1 ) . F o r a pe r c ut a -
ne o us pl ug, a n o pe ni ng i s c r e a t e d j us t a b o v e t h e
pl ug, a v o i di ng s ki n t e ns i o n a t al l c o s t s . T h e o pe ni ng
i s ma de wi t h a s ki n p un c h of t h e s a me s i ze a s t h e
pl ug pr o v i de d i n t h e ma nuf a c t ur e r ' s s ur gi c a l kit.
T h e po s t a ur i c ul a r i nc i s i o n i s c l o s e d wi t h 3- 0 a b-
s o r ba bl e s ut ur e s f or t h e s u b c u t a n e o u s t i s s ue s a nd 4 -
0 s i l k f or t h e s ki n. A P e nr o s e dr a i n c a n be us e d. Th i s
i s f o l l o we d by a ppl i c a t i o n of a ma s t o i d dr e s s i ng.
Mastoidotomy/Tympanotomy
Approach
i
Advantages
1. T e c h ni c a l s i mpl i c i t y .
2. I nv o l v e s l e s s b o n e dr i l l i ng a nd t i s s ue r e mo v a l .
3. Ca r r i e s a l mo s t no r i s k t o t h e f aci al ne r v e .
4 . Al l o w; f or di r e c t v i e w o f a nd wo r k i n t h e r o und
wi n d o w ni c h e s .
5. Ac t i v e e l e c t r o de i s c o v e r e d by a t h i c k l a y e r of
t i s s ue a l o ng i t s e nt i r e c o ur s e ( no t j us t s ub c ut a ne -
o us l y ) .
6. P r o v i de s a be t t e r a ng l e i n t h e ba s a l t ur n of t h e
c o c h l e a f or s l i di ng t h e e l e c t r o de , ma k i n g ful l i ns e r t i o n
e a s i e r .
289 Surgical Approaches for Cochlear Implants
Round window niche
FIGURE 16-2
Internal receiver seat
B
Surgical Approaches for Cochlear Implants
FIGURE 16-1.
288
S ur gi c a l Ap p r o a c h e s f or Co c h l e a r I mpl a nt s
FIGURE 16 - 3
S ur gi c a l Ap p r o a c h e s f or Co c h l e a r I mpl a nt s 2 9 1
Internal receiver
1
FIGURE l( M
2 92 S ur gi c a l Ap p r o a c h e s f or Co c h l e a r I mpl a nt s
7. S ma l l po s t a ur i c ul a r f l ap c a r r i e s l e s s r i s k o f h e -
ma t o ma o r i nf e c t i o n; r e qui r e s no dr a i ns ; ma k e s h e a l -
i ng e a s i e r ; a nd a l l o ws no t e ns i o n o f t h e s ki n wi t h
pe r c ut a ne o us pl ugs .
8 . Al l o ws f a s t e r r e c o v e r y a nd s h o r t e r h o s pi t a l i za -
t i on
Surgical Steps
1. Enda ur a l i nc i s i o ns ( L e mpe r t 1 a nd II) .
2. Ca na l i nc i s i o ns at 6 a nd 2 o ' c l o c k.
3. Ex po s ur e o f t h e mi ddl e e a r .
4. . Dr i l l i ng o f t h e r o und wi n d o w ni c h e a nd vi s -
a l i za t i o n o f t h e r o und wi n d o w me mb r a n e .
5. S ma l l a t t i c o t o my .
6 . Ma s t o i d o t o my .
7. P o s t a ur i c ul a r i nc i s i o n.
8 . Re mo v a l o f t e mpo r a l mus c l e a nd pe r i o s t e um
9. Dr i l l i ng of a s e a t for t h e i nt e r na l r e c e i ve r .
1 0. T u n n e l i n g o f t he e l e c t r o de f r om t h e po s t a ur i c -
ul a r i nc i s i o n i nt o t h e ma s t o i d o t o my o pe ni ng
11. I nt r o duc t i o n o f t h e e l e c t r o de i nt o t h e a nt r um
a n d mi ddl e e a r
12. I ns e r t i o n o f t h e e l e c t r o de i nt o t h e c o c h l e a .
13. S e c ur i ng o f t h e i nt e r na l r e c e i ve r .
14. Cr e a t i o n of a s ki n o pe ni ng ( f or pe r c ut a ne o us
r e c e i v e r s ) .
15. Cl o s ur e , pa c ki ng, a nd a ma s t o i d dr e s s i ng.
Procedure
T h e first i nc i s i o n ( L e mpe r t I ) i s ma d e s e mi c i r c um-
f e r e nt i a l l y b e t we e n 6 a nd 12 o ' c l o c k on t h e po s t e r i o r
wa l l a t t h e b o ny c a r t i l a gi no us j unc t i o n. T h e s e c o nd
i nc i s i o n ( L e mpe r t II) r uns b e t we e n t h e t r a gus a nd
h e l i x (at t h e i nc i s ur a ) . T h e e x t e ns i o n o f t h i s i nc i s i o n
i s a ppr o x i ma t e l y 0. 7 5 c m. T h e po s t e r i o r c a na l s ki n
( c a r t i l a gi no us po r t i o n) i s pr e s e r v e d a nd ge nt l y el e-
v a t e d wi t h a s ma l l pe r i os t e a l e l e va t o r , c l e a r l y e x po s -
i ng t h e e nt i r e po s t e r i o r b o ny c a na l ( Fi g. 1 6 - 5 / 1 ) . T wo -
pr o ng r e t r a c t o r s a r e us e d for e x po s ur e ; o c c a s i o na l l y
t h r e e - pr o ng r e t r a c t o r s a r e ne e de d.
Wi t h a s c a l pe l , ve r t i c a l i nc i s i o ns a r e ma d e at 6 a nd
2 o ' c l o c k. In a c o mpl e t e l y dr y f i el d, a fl ap is e l e v a t e d
a n d t h e mi ddl e e a r c a vi t y i s e nt e r e d b e ne a t h t h e
a nnul us . Al l a n a t o mi c s t r uc t ur e s a nd l a ndma r ks a r e
v i s ua l i ze d. Us i ng s t a pe s c ur e t s , t h e po s t e r i o r c a na l
wa l l i s e nl a r ge d a nd a s ma l l a t t i c o t o my i s d o n e ( Fi g.
1 6 - 5 8 ) . S pe c i a l a t t e nt i o n i s pa i d t o t h e r o und wi n d o w
ni c h e . T h e a nt e r o s upe r i o r po r t i o n i s r e mo v e d wi t h a
s ma l l b ur a nd t h e r o und wi n d o w me mb r a n e i s
b r o ugh t di r e c t l y i nt o v i e w ( Fi g. 1 6 - 5 C) . An y a ddi -
t i ona l dr i l l i ng n e e d e d f or e x po s ur e i s de l a y e d unt i l
t h e e l e c t r o de i s i ns e r t e d ( s e e P o s t e r i o r T y mp a n o t o my
[ Fa c i a l Re c e s s ] Ap p r o a c h ) .
A pi e c e of Ge l f o a m i s us e d t o c o v e r t h e r o und
wi n d o w a nd a l a r ge pi e c e of c o t t o n i s pl a c e d o v e r
t h e e a r c a na l . T h i s a v o i ds c o nt a mi na t i o n b y b o ne
dus t a n d de b r i s f r o m t h e ma s t o i d o t o my dr i l l i ng.
A ma s t o i d o t o my i s do ne by dr i l l i ng i n t h e f ossa
ma s t o i de a t o wa r d t h e a nt r um ( Fi g. 1 6 - 5 D ) . Th e
o pe ni ng s h o ul d b e l a r ge e n o u g h t o vi s ua l i ze t he
a nt r um. T h e po s t e r i o r e dg e i s b e v e l e d a nd all s h a r p
b o ny e dg e s a r e s mo o t h e d . T h e i nc us i s di s a r t i c ul a t e d
f r om its s t a pe s a nd ma l l e us a t t a c h me n t s wi t h a j oi nt
kni f e a nd t ot a l l y r e mo v e d. I f de s i r e d, a d u mmy
e l e c t r o de c a n b e i ns e r t e d t h r o ugh t h e ma s t o i do t o my
o pe ni ng a nd i nt o t h e ni c h e t o ve r i f y t h e a de qua c y o f
t h e e x po s ur e . T h e mi ddl e e a r a n d ma s t o i d a r e t h e n
fil l ed wi t h a n a nt i bi o t i c s o l ut i o n.
A po s t a ur i c ul a r i nc i s i o n i s n e e d e d f or t he s ol e
pur po s e of pl a c i ng t h e i nt e r na l r e c e i ve r ; i t s h o ul d be
ma d e a t o r a b o v e t h e l i ne a t e mpo r a l i s , a l l o wi ng
e n o u g h s pa c e wi t h o ut i nt e r f e r i ng wi t h t h e us e o f
e y e gl a s s e s . Li do c a i ne ( Xy l o c a i ne ) 2% wi t h 1: 100, 000
e pi ne ph r i ne i s i nj e c t e d. T h e c i r c umf e r e nt i a l i nc i s i on
me a s u r e s 3 t o 3. 5 c m a nd i s d e e p e n e d t h r o ugh t he
s u b c u t a n e o u s t i s s ue s unt i l t h e t e mpo r a l mus c l e i s
r e a c h e d ( Fi g. 1 6 - 5 E, F). T h e s e a t s i ze f or t h e i nt e r na l
r e c e i v e r i s me a s ur e d , a nd t h e c o r r e s po ndi ng unde r -
l y i ng t e mpo r a l mus c l e a nd pe r i o s t e um a r e r e mo v e d.
T h e pe r i o s t e um i s s a v e d f or gr a f t i ng t h e r o und wi n-
d o w ni c h e . T h e b o n e s e a t i s dr i l l e d d o wn t o a c c o m-
mo d a t e t he r e c e i v e r ( Fi g. 1 6 - 6 / 1 ) a nd, de pe ndi ng
upo n t h e t y pe o f r e c e i ve r , a ddi t i o na l Iw4es a r e dr i l l ed
e i t h e r f or s ut ur e s o r for s c r e w pl a c e me nt ( s e e Po s t e -
r i or T y mp a n o t o my [ Fa c i a l Re c e s s ] Ap p r o a c h ) .
An e l e c t r o de gui de i s pa s s e d f r o m t h e e nda ur a l t o
t he po s t a ur i c ul a r i nc i s i o n bv t unne l i ng i t b e ne a t h t he
t e mpo r a l mus c l e . An e l e c t r o de gui de , wh i c h i s s i m-
il ar t o a n a nt r um t r o c a r , i s s pe c i a l l y c ur v e d a nd h a s
a bl unt di s t al o pe ni ng t o a vo i d d a ma g i n g t h e e l e c -
t r o de ( Fi g. 1 6 - 6 8 ) . T h e o b t ur a t o r i s r e mo v e d a nd t he
e l e c t r o de i nt r o duc e d i nt o t h e gui de ( Fi g. 1 6 - 6 C) ; t he
gui de i s t h e n wi t h dr a wn a nd, wi t h it, t h e e l e c t r o de
i s c a r r i e d i nt o t h e ma s t o i d o t o my o pe ni ng . I t i s t h e n
pa s s e d t o t h e a n t r um a nd i nt o t h e mi ddl e e a r . T h e
e x po s e d r o und wi n d o w me mb r a n e i s de t a c h e d wi t h
a n a ng l e d pi c k, a nd t h e e l e c t r o de i s i nt r o duc e d wi t h
a no ns e r r a t e d b a b y a l l i ga t or f o r c e ps i n a n a ngl e
po i nt i ng t o wa r d t h e ba s a l t ur n o f t h e c o c h l e a , i m-
me di a t e l y pa s t t h e h o o k ( Fi g. 1 6 - 6 D ) . T h e o pe ni ng
o f t h e r o und wi n d o w i s s e a l e d wi t h pe r i o s t e um
wr a p p e d a r o und t h e e l e c t r o de ( Fi g. 1 6 - 7 A) . S ma l l
pi e c e s o f Ce l f o a m a r e t h e n pl a c e d l at er al t o t he
S ur gi c a l Ap p r o a c h e s f or Co c h l e a r I mpl a nt s 2 93
FIGURE 16 -5
Ground electrode
Surglcal Approaches for Cochlear Implants 295
A
FIGURE 1&--7
Surgical Approaches for Cochlear Implants 294
2 96 S ur gi c a l Ap p r o a c h e s for Co c h l e a r I mpl a nt s
pe r i o s t e um gr af t . Wi t h a S y mb i o n i mpl a nt , t h e pr o-
mo n t o r y e l e c t r o de i s po s i t i o ne d o v e r t he pr o mo nt o r y
a nd s e c ur e d wi t h a c o v e r i ng of pe r i o s t e um gr af t a s
we l l .
T h e i nt e r na l r e c e i ve r i s t h e n s e c ur e d i n pl a c e wi t h
s ut ur e s o r s c r e ws ( Fi g. 1 6 - 7 B ) , t h e g r o u n d e l e c t r o de
(if s e pa r a t e ) i s pl a c e d i n t h e t e mpo r a l mus c l e f i ber s ,
a nd t h e r e s t of t h e pe r i o s t e um i s us e d t o seal , t he
a nt r um. I f a pe r c ut a ne o us pl ug i s b e i ng us e d, i m-
p e d a n c e i s c h e c k e d a t t hi s po i nt . An o pe ni ng for t he
pl ug i s ma d e a nt e r i o r t o t he pe r i a ur i c ul a r i nc i s i o n
wi t h a s ki n punc h of t h e s a me s i ze a s t h e pl ug ( Fi g.
1 6 - 7 C) . S ki n t e ns i o n s h o ul d b e a v o i de d.
T h e c a na l f l ap i s r e po s i t i o ne d. Ge l f o a m a nd a n
a nt i bi o t i c o i nt me nt a r e us e d i n t h e di s t al t wo t h i r ds
o f t h e c a na l , a n d g a uz e i s e mb e d d e d i n a nt i bi o t i c
o i nt me nt i n t h e di s t a l o n e t h i r d. I nc i s i o ns a r e c l o s e d
wi t h s u b c u t a n e o u s 3- 0 c h r o mi c c a t gut a nd s ki n s u-
t ur e s o f 4- 0 s i l k ( Fi g. 1 6 - 7 D ) , a nd a ma s t o i d dr e s s i ng
i s a ppl i e d.
CHAPTER 17
Surgery for ;
Incapacitating
Peripheral Vertigo
Th e t i t l e o f t hi s c h a pt e r h a s b e e n pur po s e l y s e -
l ect ed t o i ndi c a t e t ha t t h e s ur gi c a l pr o c e dur e s de -
s cr i bed h e r e a r e de s i g ne d f or t r e a t me nt o f v e r t i go o f
l a by r i nt h i ne o r i gi n. At t h e s a me t i me , t h e t e r m "i n-
c a pa c i t a t i ng" i mpl i e s t h a t s y mp t o ms a r e stil l pr e s e nt
after a de qua t e me di c a l e v a l ua t i o n a nd t r e a t me nt . I t
i s unde r s t o o d, t h e r e f o r e , t ha t t h e s e pr o c e dur e s a r e
pe r f o r me d i n a s ma l l pe r c e nt a ge of pa t i e nt s , s i nc e i n
t he ma j o r i t y o f c a s e s me di c a l t r e a t me nt a l o ne wi l l
s uf f i ce. ( Ev a l ua t i o n a nd me di c a l t r e a t me nt a r e out -
s i de t h e s c o pe of t hi s b o o k. ) I n a ddi t i o n, i t s h o ul d
be ke pt i n mi nd t ha t ve r t i go i s a ma ni f e s t a t i o n of an
unde r l y i ng pr o b l e m t h a t mus t b e a s s e s s e d a nd (if
pos s i bl e ) de f i ne d; d e p e n d i n g o n t h e c a us e , di f f e r e nt
s ur gi cal a l t e r na t i ve s wi l l be s e l e c t e d. T h i s i s o n e o f
the a r e a s i n o t o l o gy wh e r e o ur l a c k o f t r ue k n o wl e d g e
i s mo s t e v i de nt ; t h e r e f o r e , c a r e f ul a nd no nde s t r uc t i v e
c h o i c e s a r e r e c o mme n d e d i f at al l po s s i bl e .
Sur gi c a l pr o c e dur e s c a n b e de s t r uc t i v e o r c o ns e r -
vat i ve i n na t ur e . T h e y ma y be a i me d a t dr a i ni ng a n
a s s ume d e n d o l y mp h a t i c h y dr o ps , wh e t h e r a t t h e
e ndo l y mph a t i c s a c l e ve l o r a t t h e s a c c ul e , t h e y ma y
i nvol ve de s t r uc t i o n o f t h e l a by r i nt h ( l a b y r i nt h e c -
t o my ) a nd/ o r s e c t i o ni ng o f t he v e s t i b ul a r ne r v e o r
ot h e r ne r v e s , s uc h a s t h e s i ngul a r ne r v e o f t h e
pos t e r i or s e mi c i r c ul a r c a na l . No n e o f t h e ma n y s ur -
gical pr o c e dur e s a va i l a bl e a r e uni ve r s a l l y a c c e pt e d o r
pr ovi de 1009c r el i ef . T h e s e a r e f a c t or s t o ke e p i n
mi nd wh e n s e l e c t i ng a s pe c i f i c a ppr o a c h . Th i s c h a p-
ter wil l de s c r i b e t h o s e t ha t a r e us e d or di s c us s e d
mos t c o mmo n l y , wi t h o ut i mpl y i ng t ha t t h o s e not
de s c r i be d a r e us e l e s s o r uni mpo r t a nt .
Endolymphatic Sac Procedures
T h e s e pr o c e dur e s c o ns t i t ut e a c o ns e r v a t i v e , us u-
al l y e f f i c i e nt a ppr o a c h for v e r t i go , a nd a r e t h e initial
c h o i c e ( no t u n c o mmo n l y t h e o nl y c h o i c e ne c e s s a r y )
o f ma n y s ur g e o ns . De s pi t e t h e l o c a t i o n o f t h e s a c i n
t he po s t e r i o r f os s a dur a , k n o wl e d g e o f its a n a t o my
a nd a de qua t e s ur gi c a l t e c h ni que us ua l l y pe r mi t a
s a f e o pe r a t i o n. I n t he e v e nt o f f a i l ur e , a ny o t h e r
pr o c e dur e c a n b e d o n e wi t h o ut a dde d di f f i c ul t y
Aim
To i de nt i f y a nd e x p o s e t h e e n d o l y mp h a t i c s a c
o v e r l y i ng t h e dur a ma t e r o f t h e po s t e r i o r c r a ni a l
f o s s a .
Highlights and Surgical Steps
1. P e r f o r m a c o mpl e t e s i mpl e ma s t o i de c t o my .
2. Dr i l l t o, b ut not b e l o w, t h e d o me of t h e hor i -
zo nt a l s e mi c i r c ul a r c a na l .
3. I de nt i f y, pr e s e r v e , a nd me a s ur e t h e h a r d a ngl e
c o nt a i ni ng t he po s t e r i o r s e mi c i r c ul a r c a na l .
4. I de nt i f y t h e po s i t i o n o f t h e s i gmo i d s i nus a nd
its r e l a t i o ns h i p t o T r a u t ma n n ' s t r i a ngl e .
2 98 S ur g e r y for I nc a pa c i t a t i ng P e r i ph e r a l Ve r t i go
I . D e c o mp r e s s t h e l a t e r a l s i nus a nd di s s e c t t h e
i nf r a l a b y r i nl h i ne cel l t r act .
6. I nc i s e t h e e n d o l y mp h a t i c s a c .
Pitfalls
1. S ke l e t o ni z i ng or d a ma g i n g t h e po s t e r i o r s e mi -
c i r c ul a r c a na l .
2. I ns uf f i c i e nt l y unr o o f i ng t h e dur a l pl a t e .
3. Fa i l i ng t o i de nt i f y t h e e n d o l y mp h a t i c s a c a nd
i t s l ume n.
4. D a ma g i n g t h e i nc us .
5. De b r i s i n t h e mi ddl e e a r .
6. Bl e e d i n g i n t h e l at er al s i nus ,
Procedure
I n e n d o l y mp h a t i c s a c s ur ge r y , a t h o r o ugh s i mpl e
ma s t o i d e c t o my ( s e e Ch a pt e r 7) i s a dv o c a t e d. Dur i ng
t h i s s t e p t h e b o ny pl a t e o v e r l y i ng t h e po s t e r i o r c r a -
nial f os s a dur a i s i de nt i f i e d. T r a u t ma n n ' s t r i a ngl e i s
de f i ne d a nd t h e h a r d b o n e c o nt a i ni ng t h e po s l e r i o r
s e mi c i r c ul a r c a na ! i s i de nt i f i e d ( Fi g. \7-\A. H). Th e
s a c c o me s t o wa r d t h e dur a f r om t h e di r e c t i o n o f ( h e
po s t e r i o r s e mi c i r c ul a r c a na l a nd c a n b e i de nt i f i e d a s
i t e xi t s ( h e h a r d a ngl e i nt a c t . A go o d me t h o d of
pr e v e nt i ng d a ma g e t o t h e po s t e r i o r s e mi c i r c ul a r c a na l
i s t o me a s ur e t h e a r e a c o nt a i ni ng t hi s s t r uc t ur e , uul
l e a v e i t unt o uc h e d ( undr i l l e d) . Wi t h a l e ne s t r o ni e t e r ,
me a s ur e HI mm f r om t h e tip of t h e s h or t pr o c e s s ot
t h e i nc us or f os s a i nc udi s , a l o ng [ h e a \ i s ol [ he
h o r i zo nt a l s e mi c i r c ul a r c a na l ( 30 de g r e e s f r om t h e
l e g me n ) ; t h e n me a s ur e 12 mm f r om I h e l oss. i i mu d i s
a t a n a ngl e ot I S de g r e e s k o n i t h e l e g me n l l i g . 17
\H). Th i s ar e. i i s lett unt o uc h e d wh i l e ( h e i nl r a l . i l n-
r i nt h i ne cel l t r act is dr i l l ed I n e x po s e t h e s a c l o c a t i o n
( Fi g. \7-\H. C) . S pe c i a l a t t e nt i o n i s pai d t o t h e
po s i t i o n o f ( l i e s i gmo i d s i nus ( Fi g. 1 7 - 2 / 1 ) ; o n o c c a -
s i o n, i t pa r t i a l l y o v e r l i e s ( h e dur a l pl a t e , r e duc i ng
t h e s i ze o f T r a ut ma n n ' s t r i a ngl e ( i nt e r e s t i ngl y , t hi s
i s fair l y c o mmo n i n pa t i e nt s wi t h Me ni e r e ' s di s e a s e ) .
T h e pl a t e i s t h i nne d d o wn t o e ggs h e l l t h i c kne s s ,
t h e n ge nt l y e l e v a t e d a n d s e pa r a t e d f r om t h e unde r -
l y i ng dur a wi t h a duc kb i l l e l e v a t o r . T h e s a c i s i de n-
t i f i abl e a s a t h i c ke ne d wh i t e a r e a of t h e dur a ewer
t h e t hi n s ur r o undi ng dur a ( Fi g. I 7 - 2 R ) . T h e po s t e r i o r
s e mi c i r c ul a r c a na l s h o ul d not b e t h i nne d o r s ke l e t o n-
i ze d. Dr i l l i ng i s d o n e i mme di a t e l y i nf e r i or t o this
a r e a . If t h e l at er al s i nus is in s uc h a po s i t i o n t hat it
t e nds t o pa r t i a l l y c o v e r t h e dur a o r ma k e a c c e s s t o i t
di f f i cul t , t h e pa t i e nt ' s po s i t i o n s h o ul d be c h e c k e d
first; t h e h e a d mi gh t be be nt t o o far f o r wa r d. I f a f t e r
r e po s i t i o ni ng t h e h e a d of t h e pa t i e nt t h e s i nus i s stil l
pr o mi ne nt , i t s h o ul d be d e c o mp r e s s e d by r e mo v i n g
par t o f its b o ny c o v e r i ng l a c i ng t h e dur a , i nf r a l a by -
r i nt h i ne c e l l s ma y h a v e t o b e dr i l l e d ( l e a di ng t o wa r d,
t h e j ugul a r b ul b ) . T h e s a c i s i de nt i f i e d.
At t h i s po i nt , t h e r e a r e s e ve r a l a l t e r na t i v e s :
1. D e c o mp r e s s i o n of t h e s a c ( r e mo v a l of t h e b o n y
c o v e r i ng) i s al l t ha t i s do ne .
2. T h e s a c i s i nc i s e d i n its l at er al s ur f a c e wi t h a
s h a r p kni f e ( f or e x a mp l e , a s i c kl e kni f e ) . Th i s i s t h e
or i gi na l ( a nd c ur r e nt ) P o r t ma nn pr o c e dur e ( Fi g. 17-
2 C) .
3. A va l ve i s pl a c e d i n t h e l ume n (in t h e e x pe c t a -
t i on t ha t mi c r o l i t e r s o f e x c e s s i v e e n d o l y mp h wi F
dr a i n) .
4. A s ma l l i nc i s i o n i s ma d e on t h e me di a l s ur f a c e
of t h e s a c i n o r de r t o o pe n up t h e s ub a r a c h no i d
s pa c e . I nt o t hi s o pe ni ng a f l a nge d Te f l o n t ub e i s
i ns e r t e d. The o ut e r s ur f a c e i s t i gh t l y pa c ke d ( a pi e c e
o f f as ci a c a n be us e d) .
5. A t hi n pi e c e of Si l a s t i c s h e e t i ng ( 0. 01 c m) i s c ut
i n a T- s h a pe d f a s h i o n a nd pl a c e d i n t h e l ume n. S ma l l
pi e c e s o f Si l a s t i c s h e e t i ng ( s pa c e r s ) a r e us e d t o s e p-
a r a t e t h e dur a f r om t h e f l oor o f t h e po s t e r i o r c a na l .
A S i l a s t i c " a p r o n " i s a ppl i e d a nd h e l d i n pl a c e wi t h
C- el f oam ( Fi g. 1 7 - 3 / 1 - D ) .
1 l ie ma s t o i d c a v i t y i s pa c ke d wi t h Ge l t o a m o v e i
t h e d e c o mp r e s s e d a r e a , and t h e incision is c l o s e d in
l avers wi t h a ppr o pr i a t e Mitures. At t h e end of t h e
pr o c e dur e , a ve nt i l a t i o n tube ma \ ho pl a c e d i n t h e
t v mpa ni c me mb r a n e ( Fi g. I 7- - 3/ V
1 1
i s i mpo r t a nt t o
t h o r o ugh l y cl eanse the ma s t o i d c a\
1
' he I ore c l o s ur e .
I h e e f f e c t i v e ne s s o f t hi s pr o c e dur e ma v h e due t o
d e c o mp r e s s i o n ol o v e i l v i ng h o ne , dr a i na ge of e n
d o l v mp h bv o pe ni ng ol I h e sac, i nc r e a s e d va s c ul a r -
i t y, or o t h e r l acl ors, ,i di si ussion is o ut s i de the s c o pe
nl t h i s b o o k. I h e l a d r e ma i ns t hat a nv pr o c e dur e '
t hat i nv o h es o pe ni ng t h e s a c h a s c o mpa r a b l e r e s ul t s .
Co mpl i c a t i o ns a r e t h o s e o f ma s t o i de c t o my ( s e e
Ch a pt e r 7) , o pe ni ng o f t h e po s t e r i o r s e mi c i r c ul a r
c a na l , a nd c e r e b r o s pi na l fl uid f i s t ul a e . T h e be s t t r eat - '
mer i t i s pr e v e nt i o n. T h e t e c h ni que o f i s ol a t i ng t h e
h a r d a ngl e i s pr a c t i c a l . I f t h e po s t e r i o r s e mi c i r c ul a r
c a na l i s a c c i de nt a l l y o p e n e d , t h e f i st ul a s h o ul d be
gr a f t e d i mme di a t e l y ; h o we v e r , a " de a d e a r " i s a l mo s t
c e r t a i n. Fi s t ul a e t h a t l e a k c e r e b r o s pi na l f l ui d a r e
u n c o mmo n a nd s e l f - l i mi t i ng; h i g h - do s e a nt i b i o t i c s
s h o ul d be us e d i n o r de r t o a v o i d me ni ngi t i s . It i s
u n c o mmo n t o h a v e t o r e - e x pl o r e a nd pl a c e a l a r ge
pi e c e o f f as ci a a nd mus c l e ( a l o ng wi t h t i ght pa c ki ng
o f t h e ma s t o i d e a vi t v wi t h Ce l f o a m) .
S ur ge r y f or I nc a pa c i t a t i ng P e r i ph e r a l Ve r t i g o
FIGURE 17-1
300 Surgery for Peripheral Ver";;n
Surgery for Incapacitating Peripheral Vertigo 301
T-strut IOserted
0.01 ern Silastic
Apron
E
IICUgl: 17-2.
HCUgE 17-}
302 S ur g e r y f or I nc a pa c i t a t i ng P e r i ph e r a l Ve r t i go
Saccule Procedures
T h e s e a r e me n t i o n e d for t h e s a ke o f c o mp l e t e n e s s
a nd a n o ve r a l l c o nc e pt . T h e mo s t c o mmo n ( s uc h a s
t h e Fi c k a nd t a c k pr o c e dur e s ) a r e a s s o c i a t e d wi t h
s e v e r e , i r r e ve r s i bl e s e ns o r i ne ur a l h e a r i ng l o s s a nd
a r e r a r e l y us e d. ( An i nt e r me di a t e , s a f e r a l t e r na t i ve
us e d o c c a s i o na l l y i n c a s e s o f o t o s c l e r o s i s a s s o c i a t e d
f l f c i t h h y dr o ps i s a wi r e c o nne c t i v e t i s s ue pr o s t h e s i s
wi t h a s ma l l pe g [ f r om t h e wi r e a r o un d t h e c o nne c -
t i ve t i s s ue ] [ Fi g. 1 7 - 4 4 ) ; t h i s i s de s c r i b e d i n Ch a pt e r
1 3 . ) Bo t h pr o c e dur e s a r e i nt e nde d t o d e c o mp r e s s a
di l a t e d s a c c ul e un d e r t h e a nt e r i o r po r t i o n o f t h e oval
wi n d o w, wh i c h i s c l e a r l y e x p o s e d . T h e v a r e do ne
t h r o ugh a t r a ns c a na l a ppr o a c h . T h e Fi c k o pe r a t i o n
i nv o l v e s o p e n i n g t h e f o o t pl a t e a nd t h e n t h e s a c c ul e
( Fi g. 1 7 - 4 C) , wh e r e a s t h e t a c k pr o c e dur e i nv o l v e s
t h e pl a c e me nt of a s h a r p t a c k t h r o ugh t h e f o o t pl a t e
( a nt e r i o r a s pe c t ) ( Fi g. 1 7 - 4 8 ) . I t i s i mpo r t a nt t o seal
t h e f o o t pl a t e wi t h c o nne c t i v e t i s s ue . T h e t a c k "de -
I c o mp r e s s e s " t h e s a c c ul e wh e n i t b e c o me s di l a t e d.
Cl o s ur e i s s i mi l a r t o t hat for a s t a pe de c t o my .
Singular Neurectomy
1 h i s s e l e c t i ve l y de s t r uc t i v e pr o c e dur e e nt a i l s s e c -
t i o ni ng t h e ne r v e o f t h e po s t e r i o r s e mi c i r c ul a r c a na l
( . s i ngul ar ne r v e ) for t h e t r e a t me nt of b e ni gn pe r i ph -
er al po s i t i o na l ve r t i go ( c a us e d by a n a l t e r a t i on i n t he
f f l ps t e r i o r s e mi c i r c ul a r c a na l , s uc h a s c upul o l i t h i a s i s ) .
T h e ne r v e r uns pa r a l l e l t o t h e a nt e r o s upe r i o r por t i on
o f t h e r o und wi n d o w me mb r a n e ( Fi g. 1 7 - 5 / 1 ) .
f t T h e r o und wi n d o w ni c h e i s e x po s e d via a t r a ns -
c a na l a ppr o a c h . I f ne c e s s a r y , ( h e po s t e r o i nf e r i o r
c a na l wa l l i s c ur e t t e d for be t t e r e x po s ur e . T h e b o nv
r o und wi n d o w ni c h e i s dr i l l ed c a r e f ul l y wi t h a s ma l l
b ur a nd t h e a nt e r o s upe r i o r po r t i o n o f t h e r o und
wi n d o w me mb r a n e i s e x po s e d ( Fi g. 1 7 - 5 H) . T h e b o ne
Ht mc d i a t e l y a nt e r i o r t o t h e me mb r a n e i s t h i nne d
d o wn ( wi t h o ut i nv o l v i ng t h e me mb r a n e a nd l e a vi ng
a pi e c e o f b o n e i nt a c t b e t we e n t h e me mb r a n e a nd
t h e t h i nne d a r e a ) . T h e ne r v e i s 1.5 t o 2 mm de e p
( s l i gh t l y d e e p e r i s t h e ba s a l t ur n of t h e c o c h l e a ) ; i t i s
r e nt i f i e d a nd s e c t i o ne d wi t h a n a ngl e d h o o k ( Fi g.
p5 C) , a nd t h e a r e a i s c o v e r e d wi t h Ge l f o a m.
I T h i s pr o c e dur e i s mo r e e a s i l y de s c r i b e d t h a n per -
f o r me d. It i s qui t e di f f i cul t t o f i nd t h e ne r v e {e v e n i n
a t e mpo r a l b o n e i n t h e l a b o r a t o r y ) . Fo r a ny b o dy
a t t e mpt i ng t h i s pr o c e dur e , a r e a s o na b l e n u mb e r of
t e mpo r a l b o n e di s s e c t i o ns a r e r e c o mme n d e d .
De s t r uc t i o n o f t h e po s t e r i o r l a by r i nt h by ul t r a-
s o und ( Ar s l a n' s pr o c e dur e ) i s not de s c r i b e d i n t hi s
b o o k. Its i ndi c a t i o ns a r e f e w a nd c a n be c o v e r e d by
t he o t h e r pr o c e dur e s ; f ur t h e r mo r e , t h e a ut h o r h a s
no e x pe r i e nc e wi t h it. T h e r e a de r i s r e f e r r e d t o t h e
l i t e r a t ur e .
Labyrinthectomy
L a b y r i nt h e c t o my , a pr o c e dur e t ha t i s fair l y c o m-
mo nl y e mp l o y e d , e nt a i l s t ot al de s t r uc t i o n o f t h e
l a by r i nt h . I t s h o ul d be r e s e r v e d f or pa t i e nt s wi t h no
us a b l e h e a r i ng; e v e n t h e n, t h e s i gni f i c a nc e o f t h e
pr o c e dur e mus t be c o ns i de r e d. I s t h e c a us a t i v e di s -
e a s e bi l a t e r a l ? Co ul d i t e v e nt ua l l y b e c o me bi l a t e r a l ?
I s t h e r e a ny c h a n c e t hat t h e pa t i e nt ne e ds a c o c h l e a r
i mpl a nt ?
A l a b y r i nt h e c t o my c a n be d o n e t h r o ugh a t r a ns -
c a na l or a t r a ns ma s t o i d a ppr o a c h .
Transcanal Approach
Hi gh l i gh t s
1. Cl e a r i de nt i f i c a t i on of t h e f aci al ne r v e i s e s s e n-
tial t o a vo i d a ny po t e nt i a l l e s i o ns hi l e dr i l l i ng i n
t he ova l wi n d o w.
2 . Re mo v a l o f t h e ova l wi n d o w c o nt e nt s mus t b e
do ne wi t h o ut d e e p e n i n g t h e wi n d o w o r pus h i ng t h e
i ns t r ume nt h a r d i nt o t h e wa l l s . On l y a t hi n pl a t e
s e pa r a t e s t hi s a r e a f r om t h e i nt e r na l a udi t o r y c a na l ,
a nd a c e r e b r o s pi na l f l ui d l eak is a pot e nt i a l c o mpl i -
c a t i on.
Ex po s ur e i s o b t a i ne d via a n e x pl o r a t o r y t y mpa n-
o t o my a ppr o a c h ( s e e Ch a pt e r 5) . Bo t h t h e o va l a nd
t he r o und wi n d o ws a r e e x po s e d. I t i s i mpo r t a nt t o
vi s ua l i ze a nd i de nt i f y t h e po s i t i o n a nd s t a t us o f t h e
facial ne r v e i n r e l a t i o ns h i p t o t h e o va l wi n d o w ( Fi g.
1 7 - 6 ) . T h e s t a pe s i s r e mo v e d a nd t h e c o nt e nt s o f t h e
oval wi n d o w a r e s uc t i o ne d. Wi t h a h o o k, t h e r e s t of
t h e c o nt e nt s a r e r e mo v e d ( Fi g. 1 7 - 7 / 1 , B). T h e pr o -
mo nt o r y i s dr i l l e d a nd bo t h wi n d o ws a r e c o n n e c t e d
( Fi g. 1 7 - 7 C) . T h e l a by r i nt h i s f i l l ed wi t h Ge l f o a m
s a t ur a t e d wi t h s t r e pt o my c i n s ul f a t e .
Text continued on page 3 07
S ur ge r y f or I nc a pa c i t a t i ng P e r i ph e r a l Ve r t i go 303
Incus
FIGURE V-4
S ur ge r y f or I nc a pa c i t a t i ng P e r i ph e r a l Ve r t i go
FIGURE 17-6 .
S ur ge r y for I nc a pa c i t a t i ng P e r i ph e r a l Ve r t i go 307
Transmastoid Approach
(Transmastoid Labyrinthine
Dissection)
Aim
Co mp l e t e r e mo v a l o f t h e s e mi c i r c ul a r c a na l s a nd
the soft t i s s ue of t h e v e s t i b ul e
Highl ights
1 . T h e s i no dur a l a n g l e mus t b e c o mp l e t e l y
t h i nne d f or a de qua t e e x p o s u r e o f t h e ve s t i bul e .
2 . T h e t e g me n mus t b e t h i nne d f or a de qua t e vi s -
ua l i za t i on o f t h e s upe r i o r a s pe c t o f t h e s e mi c i r c ul a r
c a na l s .
A s i mpl e ma s t o i d e c t o my i s do ne . T h e t h r e e s e mi -
ci r cul ar c a na l s a r e s ke l e t o ni z e d unt i l t h e me mb r a n o u s
l a byr i nt h i s vi s i bl e t h r o ugh t h e b o n e a s a t hi n bl ue
l ine ( Fi g. 1 7 - 8 / 1 ) . T h e r e l a t i o ns h i p o f t h e f aci al ne r v e
t o t he h o r i zo nt a l s e mi c i r c ul a r c a na l i s de f i ne d ( Fi g.
1 7 - 8 8 ) . T h e t h r e e c a na l s a r e dr i l l e d ( o ne b y o ne ) a nd
t hei r c o nt e nt s c a r e f ul l y r e mo v e d b y s uc t i o n a nd t h e
us e o f h o o k s ( Fi g. 1 7 - 8 C) . T h e s pa c e i s fil l ed wi t h
Ge l f o a m s a t ur a t e d wi t h s t r e pt o my c i n s ul f a t e .
Retrolabyrinthine Approach to
the Cerebellopontine Angle
and Sectioning of the
Vestibular Nerve
Aim
Ex po s ur e o f t h e c e r e b e l l o po nt i ne a ngl e a nd t h e
ei ght h c r a ni a l ne r v e wi t h pr e s e r v a t i o n o f t h e l a by-
r inth.
Highlights
1. Ma nni t o l ma y be g i v e n t o a i d s h r i nka g e o f t h e
c e r e be l l um.
2. T h e a nt e r i o r l i mi t of t he di s s e c t i o n i s t h e po s -
t er i or s e mi c i r c ul a r c a na l .
3 . T h e s i gmo i d s i nus mus t b e a de qua t e l y de c o m-
pr e s s e d a nd mo b i l i z e d.
4 . Bo n e mus t b e c o mpl e t e l y r e mo v e d f r om t h e
s i no dur a l a ngl e a nd po s t e r i o r f o s s a .
5. A dur a l f l ap i s h i nge d a nt e r i o r l y a nd dr a pe d
o v e r t h e po s t e r i o r s e mi c i r c ul a r c a na l .
6. T h e s upe r i o r h a l f o f t h e e i gh t h ne r v e i s s e c -
t i o ne d.
Pitfalls
1. Fa i l i ng t o r e mo v e b o n e a de qua t e l y up t o t he
po s t e r i o r s e mi c i r c ul a r c a na l .
2. I na dv e r t e nt l y e nt e r i ng t h e l a by r i nt h .
3. Fa i l i ng t o d e c o mp r e s s t h e s i gmo i d s i nus a de -
qua t e l y , l e a di ng t 3 po o r vi s ua l i za t i o n.
4 . I nc o mpl e t e l y s e c t i o ni ng t h e ve s t i bul a r ne r v e .
5. I na dv e r t e nt l y s e c t i o ni ng t h e c o c h l e a r ne r v e f i -
be r s .
Procedure
For t h i s a ppr o a c h , t h e pa t i e nt l i es s upi ne . T h e
pr e pa r a t i o n a nd dr a pi ng o f t h e pa t i e nt a r e t h e s a me
a s f or a s t a nda r d e a r pr o c e dur e , wi t h t h e e x c e pt i o n
t h a t a l a r ge r a r e a o f t h e h e a d i s s h a v e d. T h e pa t i e nt ' s
h e a d i s po s i t i o ne d a t t h e f oot o f t h e t a bl e t o a l l o w
t h e s ur g e o n' s l e gs a mpl e r o o m b e ne a t h t h e t a bl e .
T h e pa t i e nt mus t be s e c ur e l y s t r a ppe d t o t h e t a bl e ,
s i nc e f r e que nt s i de - t o- s i de r ot a t i on i s ne e de d. Th e
pa t i e nt ' s left l ow;er a b d o me n i s a l s o pr e pa r e d a nd
dr a pe d for h a r v e s t i ng of a n a b do mi na l fat gr af t .
T h e po s t a ur i c t i l a r i nc i s i on i s ma d e a s us ua l but i s
l o c a t e d f ur t h e r po s t e r i o r l y 2 t o 3 cm (at its mo s t
po s t e r i o r po s i t i o n) t o a l l o w dr i l l i ng po s t e r i o r t o t he
s i gmo i d s i nus , t h i s i s e s s e nt i a l for c o mpl e t e de-
c o mpr e s s i o n o f t h e s i gmo i d s i nus , wh i c h pe r mi t s
pr o pe r a ngul a t i o n a nd vi s ua l i za t i o n i nt o t h e c e r e b e l -
l o po nt i ne a ngl e . T h e i nc i s i o n r uns i n a s e mi l una r
f a s h i o n a nd i s c a r r i e d t h r o ugh t h e pe r i o s t e um o f t he
ma s t o i d c o r t e x , a v o i di ng t h e t e mpo r a l mus c l e s upe -
r i or l y. T h e pe r i o s t e um i s t h e n e l e v a t e d a nd t h e e a r
h e l d f o r wa r d wi t h c e r e be l l a r r e t r a c t o r s . Re t r a c t o r s
pl a c e d i n a s upe r i o r - t o - i nf e r i o r di r e c t i o n wi l l h o l d t h e
t e mpo r a l mus c l e o ut o f t h e s ur gi c a l f i el d.
Us i ng t h e l a r ge s t c ut t i ng b ur a nd s uc t i o n i r r i ga-
t i on, dr i l l i ng i s b e g u n . T h e ma s t o i d c o r t e x i s r e mo v e d
a s i n a r o ut i ne ma s t o i de c t o my . Ca r e i s t a ke n t o
s a uc e r i ze t h e e dg e s a nd t o ke e p t h e l a t e r a l mo s t
o pe ni ng a s wi de a s po s s i bl e . Re mo v a l o f b o n e i s
e x t e nde d b e h i n d t h e s i gmo i d s i nus f or a di s t a nc e of
up t o 1 c m; t h e b o ne i s t h i nne d t o e ggs h e l l t h i c kne s s ,
S ur ge r y for I nc a pa c i t a t i ng P e r i ph e r a l Ve r t i go
FIGURI-'
S ur ge r y for I nc a pa c i t a t i ng P e r i ph e r a l Ve r t i go 309
a n d f i nal r e mo v a l f r om t h e s i gmo i d a nd dur a i s
a c c o mpl i s h e d l at er wi t h t he d i a mo n d bur . Be al er t
f or e mi s s a r y v e i ns t ha t r un f r om t h e s i gmo i d s i nus
t o t h e ma s t o i d c o r t e x.
At t h i s po i nt t he o pe r a t i ng mi c r o s c o pe i s b r o ugh t
i nt o t h e f i el d. T h e ma s t o i d e c t o my i s c o mp l e t e d a s
de s c r i b e d i n Ch a p t e r s 5 a nd 7, a n d t h e b a s i c l a nd-
ma r ks ( t h e h o r i zo nt a l s e mi c i r c ul a r c a na l , t h e i nc us ,
a nd t h e c o ur s e o f t h e f aci al ne r v e ) a r e vi s ua l i ze d.
Wi t h t h e s e l a ndma r ks , a c c ur a t e i de nt i f i c a t i o n o f t he
po s t e r i o r s e mi c i r c ul a r c a na l c a n b e ma d e . Th i s r e p-
r e s e nt s t h e a nt e r i o r l i mi t f or r e mo v a l o f b o n e a nd
e x po s ur e i nt o t he c e r e b e l l o po nt i ne a ngl e ; i f b o ne
r e mo v a l i s not c o mpl e t e up t o t he po s t e r i o r s e mi c i r -
c ul a r c a na l , a t r o ub l e s o me r i dge of b o n e wi l l h i nde r
a de qua t e e x po s ur e t o t h e a ngl e . I nt e r i o r l y t h e di s s e c -
t i on i s c o nt i nue d i nt o t h e i nf r a l a by r i nt h i ne a nd r e t r o-
facial cel l t r a c t s . Bo n e r e mo v a l i s a l s o ne c e s s a r y h e r e
for a de qua t e e x po s ur e o f t h e c e r e b e l l o po nt i ne a ng l e
a nd t h e e i gh t h c r a ni a l ne r v e . T h e po s t e r i o r f os s a
dur a i s . f o l l o we d me di a l l y a nd t h e j ugul a r bul b, i f
s upe r i o r l y l o c a t e d, i s e x p o s e d . T h e s upe r i o r l i mi t
wi t h i n t h e i nf r a l a by r i nt h i ne cel l t r act wi l l be t he h a r d
b o ne of t h e l a by r i nt h . Al t h o ug h i t i s no t ne c e s s a r y
t o " b l ue - l i ne " it, c o ns t a nt a wa r e n e s s o f t h e l o c a t i o n
of t h e de s c e ndi ng po r t i o n of t h e f aci al ne r v e i s
ne e de d t o a v o i d i nj ur y t o it. T h e e n d o l y mp h a t i c s a c
i s l o c a t e d wi t h i n t h e dur a a t t h i s l e ve l .
Bo n e r e mo v a l f r o m t h e po s t e r i o r f os s a dur a i s n o w
c o mp l e t e d wi t h t h e l a r ge d i a mo n d b ur a nd s uc t i o n
i r r i ga t i on. T h e d i a mo n d b ur a l l o ws f or s a f e r b o ne
r e mo v a l a nd a v o i ds t e a r i ng o f t h e dur a o r s i nus .
Bi l l ' s i s l a nd of b o ne i s of t e n l eft o v e r t h e s i gmo i d
s i nus t o pr o t e c t i t dur i ng r e t r a c t i on or f ur t h e r dr i l l i ng
me di a l l y
T h e dur a l o pe ni ng i s ma d e wi t h a No . 59 S Be a v e r
kni f e o r s i mi l a r s h a r p i ns t r ume nt . T h e first i nc i s i o n
pa r a l l e l s t h e s i gmo i d s i nus a nd r uns b e t we e n t he
s i nus a nd t h e e n d o l y mp h a t i c s a c i nt e r i or l y ( Fi g. 1 7 -
9/ 1) . T h e s upe r i o r i nc i s i o n pa r a l l e l s t he s upe r i o r pe -
t r os al s i nus a nd r uns i n t h e s i no dur a l a ngl e . ( Ca r e
mus t be t a ke n t o a vo i d i nj ur y t o t h e v e s s e l s a nd t h e
c e r e b e l l um i mme di a t e l y unde r t h e dur a . ) T h e dur a l
fl ap c r e a t e d i s h i nge d a nt e r o me di a l l y a t t he l e ve l of
t he po s t e r i o r s e mi c i r c ul a r c a na l ( Fi g. 1 7 - 9 8 ) ; i t i s
dr a pe d o v e r t h e c a na l a nd a s t a y s ut ur e i s pl a c e d i f
ne e de d. L o n g Co t t o no i ds a r e pl a c e d o v e r t he e x -
po s e d c e r e b e l l um (for pr o t e c t i o n) a nd ge nt l e r e t r a c -
t i on i s a ppl i e d. T h e c i s t e r na l a t e r a l i s i nf e r i or l y i s
bl unt l y pr o b e d t o pr o v i de a pr o f us e c e r e b r o s pi na l
f l ui d l e a k i f o n e h a s no t o c c ur r e d; t h i s a l l o ws t h e
c e r e b e l l um t o r e l a x. Go o d vi s ua l i za t i o n o f t h e c e r e -
b e l l o po nt i ne a ngl e a nd i t s s t r uc t ur e s i s t h e n o b t a i ne d.
T h e e i gh t h ne r v e l i es ne a r t h e l e ve l o f t h e a mpul -
l at ed e nd o f t h e po s t e r i o r s e mi c i r c ul a r c a na l a nd r uns
i n a pl a ne i n l i ne wi t h t h e h o r i zo nt a l s e mi c i r c ul a r
c a na l . Wi t h a de qua t e e x po s ur e , t he fifth ne r v e ma y
be s e e n a nt e r o s upe r i o r l y , I nf e r i or l y t he ni nt h , t e nt h ,
a nd e l e v e nt h ne r v e s c a n b e s e e n. T h e s e v e nt h ne r v e
l i es me di a l t o t h e e i gh t h a n d c a n b e vi s ua l i ze d wi t h
ge nt l e r e t r a c t i o n of t he l at t er . Of t e n t he l at er al b r a nc h
o f t h e a nt e r o i nf e r i o r c e r e b e l l a r a r t e r y i s s e e n b e t we e n
t h e s e v e nt h a nd e i gh t h c r a ni a l ne r v e r o o t l e t s ( Fi g.
1 7 - 1 0/ 1 ) . Ar a c h n o i d a dh e s i o ns ma y o b s c ur e t h e c e r -
e b e l l o po nt i ne a ngl e a nd its s t r uc t ur e s . Ca r e f ul di s -
s e c t i o n wi t h a s h a r p h o o k ma y be n e e d e d t o l ys e
t h e s e a dh e s i o ns .
At t h i s l e ve l , t h e e i gh t h ne r v e c o ns i s t s o f o ne
t r unk. T h e v e s t i b ul a r s e g me n t o f t h e ne r v e l i es s u-
pe r i o r t o t h e c o c h l e a r s e g me nt . Us ua l l y , c a r e f ul h i gh -
p o we r i ns pe c t i o n o f t h e ne r v e t r unk wi l l r e ve a l t h e
c l e a v a ge pl a ne s e pa r a t i ng t h e t wo s e g me nt s ; i t i s
of t en h i gh l i gh t e d by a s ma l l v e s s e l on t h e s ur f a c e of
t he ne r v e ( Fi g. 1 7 - 1 0 8 ) . ( In a ppr o x i ma t e l y 2 0 % o f
pa t i e nt s , t h i s pl a ne i s di f f i cul t t o di s c e r n. ) Us i ng a
s ma l l h o o k, t h e c l e a v a ge pl a ne i s de v e l o pe d. S e c t i o n-
i ng of t h e v e s t i b ul a r di vi s i o n i s do ne wi t h a s h a r p
h o o k o r mi c r o s c i s s o r s , c a r e f ul l y a v o i di ng i nj ur y t o
t h e f aci al o r c o c h l e a r ne r v e s ( Fi g. 1 7 - 1 0 C) . As t h e
ve s t i bul a r di vi s i o n i s s e c t i o ne d t h e e n d s wi l l r e t r a c t ,
l e a vi ng a 3- t o 4 - mm ga p.
Af t e r s e c t i o ni ng o f t h e ne r v e , t h e c e r e b e l l o po nt i ne
a ngl e i s i ns pe c t e d f or g o o d h e mo s t a s i s . Th e pr e vi -
o us l y h a r v e s t e d a b do mi na l fat i s cut i nt o l o ng s t r i ps ,
wh i c h a r e pl a c e d j us t i nt o t h e dur a l o pe ni ng wi t h
t h e t ai l s b r o ug h t out t o t he ma s t o i d c a vi t y . Ca r e f ul
a nd t i ght pl a c e me nt o f t h e s e s t r i ps h a s b e e n f o und
t o pr o v i de a g o o d s eal a ga i ns t po s t o pe r a t i v e c e r e b r o -
s pi na l f l ui d l e a ka ge . The l o ng t ai l s a r e t h e n f ol ded
i nt o t h e ma s t o i d a nd a nt r um, a nd t h e po s t a ur i c ul a r
i nc i s i o n i s c l o s e d. A ma s t o i d pr e s s ur e dr e s s i ng i s
a ppl i e d a nd l eft i n pl a c e f or t wo da y s .
Intraoperative Complications or
Problems
Wi t h g o o d t r a i ni ng a nd e x pe r t i s e , t hi s pr o c e dur e
i s r e ma r ka b l y fr ee of i nt r a o pe r a t i v e c o mpl i c a t i o ns .
T h e mo s t c o mmo n pr o b l e ms a r e c a us e d b y b l e e di ng
f r om i nj ur y t o t h e s i nus e s ; t h e y a r e t r e a t e d a s di s -
c us s e d i n Ch a p t e r 5 ( Tr a ns l a b y r i nt h i ne Ap p r o a c h t o
t h e I nt e r na l Audi t o r y Ca na l ) . Wi t h c a r e f ul pr e pa r a -
t i on a nd me t i c ul o us e x po s ur e , o t h e r p r o b l e ms l i s t ed
t h e r e s h o ul d b e a v o i de d. Addi t i o na l po t e nt i a l pr ob-
l e ms a r e t h o s e a c c o mp a n y i n g a ma s t o i de c t o my .
S ur ge r y f or I nc a pa c i t a t i ng P e r i ph e r a l Ve r t i go
F1CUKE 17-9
FIGURE 17-10 .
312 S ur g e r y f or I nc a pa c i t a t i ng P e r i ph e r a l Ve r t i go
Pertinent Histopathology
F I G UR E 1 7 - 1 1
Th i s t e mpo r a l b o n e wa s f r om a n i ndi vi dua l wh o
u n d e r we n t f e ne s t r a t i o n o f t h e h o r i zo nt a l s e mi c i r c ul a r
c a na l f or a v e r t i gi no us s y n d r o me . T h e v e r t i go s ub- |
s i de d t e mpo r a r i l y . Th i s s e c t i o n s h o ws t ha t wh a t I
a ppe a r t o b e s i mpl e c o ns e r v a t i v e " f e ne s t r a t i o ns "
r e s ul t i n l o c a l i ze d r e a c t i o ns wi t h n e w b o n e f o r ma t i o n. ,
S ur ge r y f or I nc a pa c i t a t i ng P e r i ph e r a l Ve r t i go 313
F I G UR E 1 7 - 1 2
Th i s pa t i e nt u n d e r we n t a n uns uc c e s s f ul " r o und s h o ws t h e ma r ke d l o c a l i ze d i nf l a mma t o r y r e a c t i o n i n
wi n d o w l a b y r i n t h o t o my " for ve r t i go . A s e v e r e s e n- t h e r o und wi n d o w ni c h e t h a t i s a s s o c i a t e d wi t h
s o r i ne ur a l h e a r i ng l o s s t ha t wa s pr e s e nt pr e o pe r a - s e e mi ng l y mi n o r s ur gi c a l t r a uma ,
l i ve l y di d not c h a n g e po s t o pe r a t i v e l y . Th i s s e c t i o n
314 S ur g e r y f or I nc a pa c i t a t i ng P e r i ph e r a l Ve r t i go
Mi ddl e c a r caviry
I- TCUKF 17- 1. 1
"1'liis pa t i e nt unde r we nt .in i i i i s v mr - s l nl l . uk pr o- not a c h i e v e i N pui po s e , bi l l s uc h l a i l ur c i s i nf r e -
t c c l ur e for . 1 v e r t i gi no us s v ml r o mc . I he o p e n i n g i n q u c n l . I h i - s e i l i on i s pr e s e nt e d i n o r de r t o Ri ve aj
t h e f oot pl a t e c o r r e s po nds t o t h e s i t e of t h e l a c k. 1 h e vi s ua l o r i e nt a t i o n t o e n d o l y mp h a t i c h y dr o ps a nd thejl
s e c t i o n s h o ws t hat i n s pi t e of t h e l a c k t h e h y dr o ps r a t i o na l e for a t a c k pr o c e dur e ,
pe r s i s t e d (nn-rnes). I n t hi s pa r t i c ul a r c a s e t h e t a c k di d
CHAPTER 18
Intratemporal Facial
Nerve Surgery
T h e a i m o f t h e pr o c e dur e s di s c us s e d i n t h i s c h a p-
t er i s t o r e - e s t a bl i s h s a f e c o nt i nui t y of t h e a x o ns of
t he f aci al ne r v e t h a t h a v e b e e n c o mp r o mi s e d by
t r a uma o r di s e a s e . Th i s r e ma i ns c o ns t a nt wh e t h e r
t he pr o c e dur e i nv o l v e s f r e e i ng, de c o mpr e s s i ng , o r
r c a na s t o mo s i ng . A c o mp l e t e di s c us s i o n of t he i ndi -
c a t i o ns f or s ur gi c a l e x pl o r a t i o n of t h e facial ne r v e or
a ny of i t s s e g me n t s i s o ut s i de t he s c o pe of t h i s a t l a s ;
t he c o mme n t s h e r e at e i nt e nde d o nl v t o c o nt r i b ut e
t o a t h o r o ugh unde r s t a ndi ng of s pe c i f i c pr o c e dur e s
I nf r a t e mpo r a l facial ne r v e pa r a l vs i s c a n be c a us e d bv
di f t e r e nt l a c t o r s a nd can in c u r i n di f f e r e nt s e g me n t s
b a s e d o n a de qua t e pr e o pe r a t i v e a s s e s s me nt , t h e re-
qui r e d pr o c e dur e mi gh t i nv o l v e a wi de mv r i ngo t -
o my , a t r a ns c a na l or t r a ns ma s t o i d a ppr o a c h , a n e x-
pl o r a t i o n of t h e first ne r v e s e g me nt a t t he i nt e r na l
a udi t o r y c a na l , or a t ot al facial ne r v e e x pl o r a t i o n.
Myringotomy
Fa c i a l pa r a l y s i s ma y o c c ur dur i ng a n a c ut e e pi s o de
of ot i t i s me di a . P e r f o r mi ng a wi de my r i n g o t o my for
dr a i na ge of pur ul e nt e f f us i o n, o b t a i ni ng a s a mpl e f or
c ul t ur e , a nd pl a c i ng a l a r ge - bo r e t ub e ( a l o ng wi t h
a de qua t e me di c a l t r e a t me nt ) wi l l s uf f i c e i n t h e ma -
j or i t y of c a s e s . It i s i mpo r t a nt t o us e a l a r ge t ub e
S ma l l t y pe I t ub e s t e nd t o b e c o me pl ug g e d, r e qui r i ng
a s e c o n d dr a i na ge pr o c e dur e .
Transmastoid Approach
Surgical Steps
1
2
3
ner v
<]
T h o s e o f a s i mpl e ma s t o i d e c t o my
T h o s e of a f aci al r e c e s s a ppr o a c h (if n e e d e d )
I de nt i f y i ng t h e di f f e r e nt s e g me n t s o f t h e facial
: a nd s ke l e t o ni zi ng t h e f aci al c a na l
R e mo v i n g t h e b o ny c o v e r i ng
Op e n i n g t h e s h e a t h o f t h e ne r v e (if i ndi c a t e d) .
Procedure
For pr a c t i c a l s ur gi c a l pur po s e s , t h e facial ne r ve
c a n be di v i de d i nt o t h r e e s e g me n t s : ( 1) wi t h i n t h e
i nt e r na l a udi t o r y c a na l a n d l a by r i nt h ; ( 2) t h e ma s t o i d
( ve r t i c a l ) ; a nd ( 3) t h e t y mpa ni c ( h o r i zo nt a l mi ddl e
e a r ) .
T h e t r a ns ma s t o i d a ppr o a c h pr o v i de s a c c e s s t o t he
t y mpa ni c a nd na s t o i d s e g me n t s o f t he ne r v e . S i mpl e
ma s t o i d e c t o my a nd f aci al r e c e s s a p p r o a c h e s h a v e
b e e n de s c r i b e d up t o t h e po i nt o f c l e a r l y i de nt i f y i ng
t he f aci al ( f a l l o pi a n) c a na l . T h e a n a t o my o f t h e c a na l
s h o ul d n o w b e r e a s s e s s e d ( Fi g. 1 8 - 1 / 1 ) .
Mastoid Segment. Fr o m t h e e v t o '
pr o c e e ds
31 6 I nf r a t e mpo r a l Faci al Ne r v e S ur ge r y
Cochleariform
Eustachian tube process
External genu
FIGURI- 18-1
t h e l e ve l o f t h e a nt e r i o r e dg e o f t h e di ga s t r i c r i dge
( Fi g. 1 8 - 1 A 8 ) . T h e ne r v e us ua l l y i s me di a l t o t h e
h o r i zo nt a l c a na l ( a go o d l a ndma r k) , h ut a t t i me s i t
ma y be l a t e r a l t o i t ( c o nge ni t a l l y or by i nf l a mma t o r y
di s e a s e ) or i t ma y h a v e a po s t e r i o r pr o j e c t i o n a t t h e
ge nu, l e ndi ng i t s e l f t o po t e nt i a l d a ma g e . I t i s us e f ul
t o vi s ua l i ze t h e ne r v e a nt e r i o r t o t h e di ga s t r i c r i dge ,
no t i ng h o w l at er al i t b e c o me s a s i t r e a c h e s t h e ma s -
t oi d t i p.
Tympanic Segment. T h e ne r v e a ppe a r s i n t h e r e gi o n
o f t h e c o c h l e a r i f o r m pr o c e s s a t t h e ge ni c ul a t e ga n-
gl i o n, t h e n r uns po s t e r i o r l y t o wa r d t h e ova l wi n d o w
( not u n c o mmo n l y , i t i s de h i s c e nt at t h i s po i nt ) t o a
poi nt j us t i nf e r i or a nd ge ne r a l l y me di a l ( de e pe r ) t o
t h e h o r i zo nt a l s e mi c i r c ul a r c a na l . Ex po s ur e o f t h e
t y mp a n i c s e g me n t i s h e l pe d b y e nl a r gi ng t h e a di t us
a d a nt r um. Th i s di s s e c t i o n, c o mb i n e d wi t h e nl a r ge -
me nt o f t h e facial r e c e s s a ppr o a c h , a l l o ws vi s ua l i za -
t i on a nt e r i o r l y t o wa r d t h e c o c h l e a r i f o r m pr o c e s s .
Dr i l l i ng wi t h a s ma l l b ur i s d o n e un d e r t h e i nc us
wi t h o ut d a ma g i n g or di s l o c a t i ng it; i f t h i s i s no t
po s s i b l e ( wh i c h us ua l l y i s t h e c a s e ) , t h e i nc us c a n b e
r e mo v e d wi t h a j o i nt kni f e ( Fi g. 1 8 - 2 / 1 ) . I f ne c e s s a r y ,
t h e t e ndo n o f t h e t e ns o r t y mpa ni c a n b e s e c t i o ne d,
pe r mi t t i ng e l e va t i o n o f t h e ma l l e us ; t h i s wil l a l l o w
c o mp l e t e dr i l l i ng t o wa r d t h e ge ni c ul a t e ga ngl i o n. I f
r e qui r e d f or be t t e r e x po s ur e , a n e x pl o r a t o r y t y mpa n-
o t o my f l ap ( pr e v i o us l y de s c r i b e d) c a n b e e l e va t e d
a nd a ddi t i o na l t r a ns c a na l e x po s ur e c a n b e o b t a i ne d.
T h e ma s t o i d s e g me n t c a n b e di s s e c t e d f r om t h e l evel
o f t h e f os s a i nc udi s o r f r om t h e di ga s t r i c r i dge . F r o m
t h e r i dge , i t c a n be f o l l o we d s upe r i o r l y t o t h e e xt e r na l
ge nu; a l t h o ug h t hi s a ppr o a c h i s pe r f e c t l y a c c e pt a b l e ,
t h e a ut h o r s t e nd t o f ol l ow ne r v e s pe r i ph e r a l l y r a t h e r
t h a n c e nt r a l l y a nd t o s t a r t a t t h e l e ve l o f t h e f os s a
i nc udi s . Dr i l l i ng i s d o n e wi t h par al l el s t r o ke s i n t h e
di r e c t i o n o f t h e ne r v e ( s upe r i o r t o i nf e r i or o r vi ce
v e r s a ) .
T h e e nt i r e facial c a na l s h o ul d be t h i nne d t o e gg-
s hel l c o ns i s t e nc y wi t h a d i a mo n d or po l i s h i ng bur .
Ho we v e r , t h e facial ne r v e s h e a t h s h o ul d not be
e x p o s e d wi t h t h e bur . T h e t h i nne d b o n e i s f r a c t ur e d
wi t h a pi c k a nd t h e b o n e f r a gme nt s a r e l ifted ge nt l y
wi t h a Wh i r l y b i r d, wi t h o ut us i ng t h e f aci al ne r v e a s
a f ul c r um ( Fi g. 1 8 - 2 8 ) . T h e s h e a t h i s s pl i t o p e n wi t h
a s h a r p s i c kl e kni f e or a Be a v e r kni f e ( Fi g. 1 8 - 2 C) .
S pe c i a l s i t ua t i o ns a nd h a ndl i ng o f t h e ne r v e i t s e l f a r e
de s c r i b e d b e l o w. Wh e n c l o s i ng, t h e i nc us i s r e po s i -
t i o ne d a n d h e l d i n pl a c e by s e ve r a l s ma l l pi e c e s o f
Ge l f o a m. Bo t h a r t i c ul a t i o ns ( wi t h t h e s t a pe s a nd t h e
ma l l e us ) a r e c a r e f ul l y r e po s i t i o ne d. Cl o s ur e a nd
pa c ki ng a r e d o n e a s i n a ma s t o i d pr o c e dur e . T h e
e x p o s e d ne r v e i s t h e n c o v e r e d wi t h go l d foil ( or a
s i mi l a r ma t e r i a l ) i n o r de r t o a vo i d f i br os i s a nd t i s s ue
I nt r a t e mpo r a ) Fa c i a l Ne r v e S ur ge r y 317
i ngr o wt h . Fa s c i a s h o ul d no t be us e d di r e c t l y o v e r
t h e ne r v e f i be r s .
Transcanal Approach
Th i s a ppr o a c h a l l o ws a c c e s s t o t h e t y mpa ni c s e g-
me nt o f t h e f aci al ne r v e a nd, i f e x t e nde d i nt e r i or l y,
ma k e s i t po s s i b l e t o e x p o s e t h e ma s t o i d s e g me n t
d o wn t o t h e s t y l o ma s t o i d f o r a me n. Th i s c a n b e us e d
a de qua t e l y i n a s c l e r o t i c ma s t o i d, but i n a we l l -
p n e u ma t i z e d ma s t o i d i t mi gh t r e s ul t i n a l a r ge c a vi t y
wi t h a n unde r l y i ng e x p o s e d ne r v e . Ri s ks o f i nf e c t i o n
i n t h e s e c a s e s mus t b e c o ns i de r e d. Th i s e x po s ur e c a n
a l s o b e o b t a i ne d b y a n e nda ur a l a ppr o a c h .
Procedure
A l a r ge t y mp a n o me a t a l f l ap i s c r e a t e d wi t h ver t i cal
i nc i s i o ns a t 2 a n d 6 o ' c l o c k, a nd t h e mi ddl e e a r c a vi t y
i s e nt e r e d b e n e a t h t h e a n n ul us ( s e e Ch a p t e r 7 ) . T h e
po s t e r i o r a n d s upe r i o r wa l l s a r e e nl a r ge d wi t h bur s
a nd c ur e t s t o f aci l i t at e e x po s ur e . T h e i nc us i s s e pa -
r a t e d f r o m t h e s t a pe s wi t h a j o i nt kni f e . I f ne c e s s a r y ,
t h e t e ndo n o f t h e t e ns o r t y mpa ni i s s e c t i o ne d t o
a l l o w e l e v a t i o n o f t h e ma l l e us . T h e f a l l opi a n c a na l i s
t h i nne d, t h e s h e a t h i s e x po s e d, a nd t h e pr o c e dur e i s
c o nt i nue d a s i n t h e t r a ns ma s t o i d a ppr o a c h ( i nc l udi ng
r e po s i t i o ni ng o f t h e i nc us ) . T h e fl ap i s r e po s i t i o ne d
a nd t h e c a na l i s pa c ke d ( Fi g. 1 8 - 3 ) .
Special Situations and
Manage.nent of the Nerve
T h e t e c h ni que s de s c r i b e d a s s u me t h e ne e d for
t ot al d e c o mp r e s s i o n , wh i c h i s not ne c e s s a r i l y t h e
c a s e a t all t i me s . I n c a s e s of a c ut e ma s t o i di t i s ( wi t h
a n e x p o s e d ne r v e a nd facial pa r a l y s i s ) wi t h no pe n-
e t r a t i o n o f t h e f aci al ne r v e s h e a t h by gr a nul a t i o n
t i s s ue or c h o l e s t e a t o ma , i t mi gh t be be t t e r no t t o
o pe n t h e s h e a t h . T h e r e i s a r i s k t hat t h e ne r v e c a n
b e i nv o l v e d b y t h e unde r l y i ng i nf l a mma t o r y pr o c e s s .
A t h o r o ugh ma s t o i d e c t o my wi t h a f aci al r e c e s s a p-
pr o a c h , a l l o wi ng c l e a ns i ng a n d a e r a t i o n o f t h e c a vi t y
a nd mi ddl e e a r , mi gh t s uf f i c e . I t i s a l s o po s s i b l e t hat
o p e n i n g o f t h e s h e a t h , f o l l o we d b y b ul gi ng o f t h e
ne r v e unt i l no r ma l ne r v e a r e a s a r e e x po s e d a t bo t h
e nds o f t h e b ul ge , ma y b e s uf f i c i e nt .
318 !nlratemporal Facial Nerve Surgery
Intralemporal Facial Nerve Surgery 319
Incus
Gold toil
Exposed nerve
FIGURE 1B-3
\
Exposed nerve
Whirlybird
B
Cochleariform process
A
c
32 0 i nt r a t e mpo r a l Fa c i a l Ne r v e S ur g e r y
In c a s e s of h e r pe s zo s t e r , i t i s a ppr o pr i a t e t o
d e c o mp r e s s up t o t h e ge ni c ul a t e ga ngl i o n.
F r a c t ur e s o f t h e t e mpo r a l b o n e i nv o l v i ng t h e facial
ne r v e ma y b e l o ngi t udi na l o r t r a ns v e r s e . Tr a ns v e r s e
f r a c t ur e s t e nd t o o c c ur a l o ng t h e a xi s o f t h e i nt e r na l
a udi t o r y c a na l a n d r e qui r e a mi ddl e c r a ni a l f os s a
a ppr o a c h ( de s c r i b e d b e l o w) . Lo ngi t udi na l f r a c t ur e s
i nv o l v e t h e o s s i c l e s a nd t y mp a n i c s e g me n t o f t he
f aci al ne r v e . Fr a c t ur e s t h r o ug h t h e ma s t o i d b o n e wil l
a f f e c t t h e ma s t o i d s e g me n t . Al o n g wi t h o s s i c ul o -
pl a s t y , b o n e f r a gme nt s i mp i n g i n g o n t h e ne r ve
s h o ul d b e me t i c ul o us l y r e mo v e d .
T r a u ma t o t h e ne r v e ma y a l s o be t h e r e s ul t o f
a c c i de nt a l i nj ur y by a b ur o r o t h e r i ns t r ume nt , a nd
c a n o c c ur a t a ny l e ve l . Thi s h a p p e n s mo r e c o mmo n l y
i n t h e t y mpa ni c s e g me n t o n t h e f l oor o f t h e facial
r e c e s s wh i l e t i s s ue i s b e i ng r e mo v e d . S pe c i a l c a r e
s h o ul d b e o b s e r v e d i n c a s e s o f pr e v i o us s ur gi c a l
t r a uma , wh i c h ma y b e t h e r e s ul t o f a n i na de qua t e
a ppr o a c h or a n u n c o mp l e t e d o pe r a t i o n t ha t l eft re-
s i dua l di s e a s e . In t h e s e c a s e s , i t i s ne c e s s a r y t o
c o mp l e t e t h e o r i gi na l o pe r a t i o n, r e a s s e s s a na t o mi c
l a ndma r ks , a nd t h e n r e pa i r t h e ne r v e d a ma g e .
Ma n a g e me n t o f t h e a f f e c t e d ne r v e i t s e l f i s a i me d
a t r e - e s t a b l i s h i ng s a f e c o nt i nui t y o f t h e n e r v e a x o ns ,
e i t h e r t h r o ugh d e c o mp r e s s i o n o r b y r e s t o r i ng c o nt i -
nui t y o f di s r upt e d ne r v e f i be r s . I f t h e a r e a o f di s r up-
t i on i s s ma l l , t h e e dg e s o f t h e f i be r s s h o ul d be
s e c t i o ne d s h a r pl y a nd r e po s i t i o ne d i n a n a t o mi c c o n-
t i nui t y . ( Ho we v e r , ma c e r a t e d e dg e s do no t r e ge ne r -
a t e a de qua t e l y . ) I f t h e ne r v e h a s b e e n c o mpl e t e l y
t r a ns e c t e d, t h e e d g e s s h o ul d b e s e c t i o ne d s h a r pl y
a n d b o t h e x t r e me s b r o ug h t t o ge t h e r a na t o mi c a l l y
S ut ur i ng i s e x t r e me l y di f f i cul t i n t h e s e c a s e s a nd i s
s e l do m a de qua t e ; a dh e s i v e gl ue s e r v e s t h e pur po s e
mo r e e f f e c t i ve l y.
I f t he ne r v e e dg e s c a nno t be b r o ugh t t o ge t h e r o r
i f pa r t o f t h e ne r v e mus t be r e mo v e d ( a s i n e x c i s i o n
of a n e ur o ma ) , a ne r v e gr af t i s c a l l e d for . Th i s gr af t
wi l l s e r v e a s a ma t r i x or p a t h wa y f or t h e a x o n s t h a t
a r e g r o wi n g f r om t h e pr o x i ma l po r t i o n i nt o t h e di s t al
e n d . Al t h o ug h t h e r e a r e ma n y s o ur c e s o f ne r v e
gr a f t s , b r a nc h e s o f t h e s upe r f i c i a l c e r vi c a l pl e x us
( e s pe c i a l l y t h e gr e a t e r a ur i c ul a r ne r v e ) a r e pr e f e r r e d
b e c a us e t h e y a r e f o und i n t he vi c i ni t y o f t h e o pe r a t i v e
f i el d, t h e y a r e o f a de qua t e s i ze , a n d t h e y a r e e a s i l y
o b t a i ne d. T h e gr e a t e r a ur i c ul a r ne r v e t r a v e r s e s l at-
e r a l l y t o t h e s t e r no c l e i do ma s t o i d mus c l e af t er e me r g-
i ng a r o und i t s po s t e r i o r e d g e a s a s i ngl e ne r v e t r unk.
An i nf r a - a ur i c ul a r i nc i s i o n i s d e e p e n e d t h r o ugh
s u b c u t a n e o u s t i s s ue s . Ant e r i o r a n d po s t e r i o r s ki n
f l a ps a r e de v e l o pe d, t he s t e r no c l e i do ma s t o i d muscl e-
i s e x p o s e d , a nd t h e gr e a t e r a ur i c ul a r ne r v e i s i de n-
t i f i ed. T h e ne r v e i s s e c t i o ne d s h a r pl y ( s e l e c t i ng t h e
de s i r e d l e ngt h ) , a nd t h e wo u n d i s c l o s e d i n l a y e r s
wi t h a ppr o pr i a t e s ut ur e s . T h e s h e a t h s o f t h e t wo
ne r v e s a r e a ppr o x i ma t e d ( pr o x i ma l s t ump t o pr o xi -
ma l e nd o f gr e a t e r a ur i c ul a r ne r v e , di s t al t o di s t al a
wi t h 9- 0 o r 10- 0 ny l o n s ut ur e s . Ad h e s i v e gl ue a l s d
1
c a n b e us e d.
Middle Cranial Fossa Approach
Aim
To f ul l y e x p o s e t h e l a b y r i nt h i ne s e g me n t o f t h e
f aci al ne r v e f r o m t h e ge ni c ul a t e ga ngl i o n t o t h e
i nt e r na l a udi t o r y c a na l , a nd t o pr e s e r v e h e a r i ng.
( Al t h o ug h de s c r i b e d h e r e for f aci al ne r v e e x pl o r a t i o n,
t h i s pr o c e dur e a l s o i s us e d f or r e mo v a l o f s ma l l
i nt r a c a na l i c ul a r a c o us t i c n e u r o ma s wh i l e pr e s e r v i ng
g o o d r e s i dua l h e a r i ng, a nd o c c a s i o na l l y for s e c t i o n-
i ng o f t h e v e s t i b ul a r ne r v e . )
Highlights
1 It a pr i or f aci al ne r v e e x pl o r a t i o n t h r o ugh t he
ma s t o i d a nd t y mpa ni c s e g me n t s h a s b e e n a c c o m-
pl i s h e d, a t e gme nt a l de f e c t i s ma d e wi t h a d i a mo n d
b ur a t t h e l evel o f t h e c o c h l e a r i f o r m pr o c e s s . T h i s
wi l l a i d a c c ur a t e o r i e nt a t i o n wh e n t h e mi ddl e f os s a
f l oor i s e x po s e d.
2. T h e s ur ge o n i s s e a t e d a t t h e h e a d o f t h e t a bl e
wi t h t h e pa t i e nt s upi ne .
3. Th e h o r i zo nt a l l i mb o f t h e c r a ni o t o my i s t wo -
t h i r ds a nt e r i o r a nd o ne - t h i r d po s t e r i o r t o t h e e x t e r na l
a udi t o r y c a na l .
4 . T h e a nt e r i o r l i mi t o f dur a l e l e v a t i o n i s t h e
mi ddl e me ni ng e a l a r t e r y , wi t h t h e dur a e l e v a t e d i n
a po s t c r i o r - t o - a nt e r i o r di r e c t i o n.
5. T h e mo s t c o ns i s t e nt l a ndma r k i s t h e gr e a t e r
s upe r f i c i a l pe t r o s a l ne r v e ; t h e a r c ua t e e mi n e n c e i s
h e l pf ul but i s o f t e n i ndi s t i nc t
6 . Me di a l t o t h e ge ni c ul a t e , t h e l a b y r i nt h i ne po r -
t i on o f t h e f a l l opi a n c a na l i s ve r y na r r o w; o nl y
mi l l i me t e r s s e pa r a t e t h e a mpul l a o f t h e s upe r i o r
s e mi c i r c ul a r c a na l po s t e r i o r l y f r om t h e c o c h l e a a nt e -
r i or l y.
7. Fa mi l i a r i t y wi t h t h e Ho u s e - Ur b a n r e t r a c t o r i s
r e c o mme n d e d be f o r e its us e . Its me c h a n i s m a l l o ws
for t h r e e a dj us t me nt s dur i ng r e t r a c t i o n.
I nf r a t e mpo r a l Faci al Ne r v e S ur ge r y 32 1
Pitfalls
1. Te a r i ng o f t he dur a wi t h h e r ni a t i o n a nd d a ma g e
t o t h e t e mpo r a l l o be .
2. Av ul s i o n o f t h e gr e a t e r s upe r f i c i a l pe t r o s a l
ne r v e a nd i nj ur y t o t h e facial ne r v e .
3 . Ex c e s s i v e b l e e di ng f r om t h e mi ddl e me ni ng e a l
a r t e r y.
4. I nj ur y t o t h e c o c h l e a o r s upe r i o r s e mi c i r c ul a r
c a na l .
Procedure
F o r t h i s a ppr o a c h t h e pa t i e nt l i es s upi ne , a nd t h e
s ur g e o n s i t s a t t h e h e a d o f t h e o pe r a t i ng t a bl e . T h e
i nc i s i o n e x t e n d s s upe r i o r l y t o t h e a ur i c l e ; t h us t he
h e a d s h a v e e x t e nds ne a r l y t o t h e t o p o f t h e s kul l
a nt e r i o r l y a nd po s t e r i o r l y unt i l vi r t ua l l y t h e e nt i r e
s i de o f t h e h e a d i s pr e pa r e d f or s ur ge r y .
T h e i nc i s i o n i s ma d e a ppr o x i ma t e l y 0. 5 c m a nt e r i o r
t o t h e t r a gus a nd e x t e nds po s t e r o s upe r i o r l y f or a p-
pr o x i ma t e l y 6 t o 8 c m; i t i s c a r r i e d t o t h e l e ve l of t h e
t e mpo r a l f a s c i a . Of t e n t h e s upe r f i c i a l t e mpo r a l a r t e r y
is e n c o u n t e r e d i nf e r i or l y; it is b e s t to t i e it wi t h a
s ut ur e . Th i s pl a ne o f di s s e c t i o n i s de v e l o pe d bl unt l y
a nd We i t l a ne r r e t r a c t o r s a r e pl a c e d. T h e t e mpo r a l
mus c l e i s i nc i s e d i n a T f a s h i o n wi t h t h e h o r i zo nt a l
l i mb e x t e ndi ng a l o ng t h e z y g o ma t i c a r c h f or 3 t o 4
c m; t h e mus c l e i s t h e n e l e v a t e d f r om t h e s q u a mo u s
po r t i o n o f t h e t e mpo r a l b o n e a nd t h e r e t r a c t o r s a r e
r e i ns e r t e d.
A c r a ni o t o my i s t h e n ma d e by o ut l i ni ng a f l ap
a ppr o x i ma t e l y 2 . 5 c m s qua r e wi t h a l a r ge c ut t i ng b ur
( Fi g. 1 8 - 4 / 4 ) . T h e h o r i zo nt a l l i mb s h o ul d b e l oc a t e d
s o t h a t t wo - t h i r ds of i t l i es a nt e r i o r t o t h e e xt e r na l
a udi t o r y c a na l , a nd o ne - t h i r d l i es po s t e r i o r . To a v o i d
i nj ur y t o t h e dur a , t h e c r a ni o t o my c ut s a r e dr i l l e d t o
pa pe r - t h i n t h i c kne s s . T h e " b o n e f l a p" i s f r a c t ur e d
wi t h a j o ke r or s i mi l a r b l unt i ns t r ume nt ; i t i s t h e n
c a r e f ul l y e l e v a t e d, a v o i di ng a ny t e a r i ng o f t h e dur a ,
wh i c h wo ul d l e a d t o t e mpo r a l l obe h e r ni a t i o n a nd
po s s i b l e i nj ur y . Fo r o p t i mu m vi s ua l i za t i o n, t h e f l ap
mus t be a s c l o s e t o t h e f l oor o f t h e mi ddl e c r a ni a l
f os s a a s po s s i b l e ; t h us t h e i nf e r i or c ut i s ma d e a t t h e
l evel of t h e z y g o ma t i c r oot . I f a l e dge of b o n e r e ma i ns
af t er t h e f l ap h a s b e e n e l e v a t e d, i t ma y be r e mo v e d
s h a r pl y wi t h t h e r o nge ur t o pl a c e t h e o p e n i n g a t t h e
l evel o f t h e mi ddl e f os s a f l oor . Bl e e di ng ma y o c c ur
f r om b o n e a nd f r om v e s s e l s o n t h e dur a l s ur f a c e o f
t h e t e mpo r a l l o be ; t h e f o r me r a r e s t o ppe d wi t h b o n e
wa x a nd t h e l at t er wi t h l i ght c a ut e r y . Aga i n, s pe c i a l
c a r e mu s t b e t a ke n t o a v o i d i nj ur i ng t h e dur a
T h e Ho us e - Ur b a n r e t r a c t o r i s t h e n pl a c e d o n t h e
pa r a l l e l ve r t i c a l e dg e s o f t h e c r a ni o t o my de f e c t ( Fi g.
1 8 - 4 6 ) . To pr e v e nt t h e dur a f r om b e i ng c a ug h t i n
t h e b l a de s of t h e r e t r a c t o r , i t i s r e f l e c t e d wi t h a bl unt
i ns t r ume nt f r o m t h e e d g e s o f t h e c r a ni o t o my . T h e
dur a i s t h e n ge nt l y e l e v a t e d f r o m t he mi ddl e f os s a
f l oor i n a po s t e r i o r - t o - a nt e r i o r di r e c t i o n. As t h e dur a
a nd t e mpo r a l l o be a r e e l e v a t e d me di a l l y , t h e r e t r a c t o r
bl a de i s s l o wl y a dv a nc e d t o pr o v i de t h e ne e de d
r e t r a c t i o n. T h e fir st l a n d ma r k t o be i de nt i f i e d i s t h e
mi ddl e me n i n g e a l a r t e r y a s i t e xi t s f r om t h e f o r a me n
s p i n o s um ( Fi g. 1 8 - 4 C) ; t h i s ma r k s t h e a nt e r i o r l i mi t
of dur a l e l e v a t i o n. Br i s k b l e e di ng of t e n wil l be e n-
c o unt e r e d i n t hi s a r e a , ne c e s s i t a t i ng pa c ki ng wi t h
S ur gi c e l . T h e di s s e c t i o n i s t h e n c o nt i nue d me di a l l y ,
a ga i n i n a po s t e r i o r - t o - a nt e r i o r di r e c t i o n. T h e gr e a t e r
s upe r f i c i a l pe t r o s a l ne r v e i s i de nt i f i e d; i t r uns a nt e -
r i o r l y o n t h e s ur f a c e o f t h e mi ddl e f os s a a f t e r e xi t i ng
t h e f aci al h i a t us . Ca r e f ul po s t e r i o r - t o - a nt e r i o r dur a l
e l e va t i o n wi l l a vo i d i na dv e r t e nt e l e v a t i o n o f t h i s
ne r v e , wh i c h a ul d pl a c e t r a c t i o n upo n t h e ge ni c ul a t e
ga ngl i o n a nd Mus e i nj ur y t o it, a s we l l a s t o t he
f aci al ne r v e . I n a s ma l l pe r c e nt a g e of c a s e s t he
ge ni c ul a t e ga ngl i o n i t s e l f ma y be de h i s c e nt . I f a
de f e c t h a s b e e n c r e a t e d i n t h e t e g me n dur i ng a
pr e v i o us ma s t o i de c t o my , i t i s n o w e nc o unt e r e d. T h e
s ur g e o n wi l l k n o w t h a t t h e ge ni c ul a t e ga ngl i o n i s
j us t me di a l t o it.
T h e ne xt l a ndma r k t o be i de nt i f i e d i s t he a r c ua t e
e mi n e n c e , wh i c h ma r ks t h e d o me o f t h e s upe r i o r
s e mi c i r c ul a r c a na l . Th i s i s no t a c o ns i s t e nt l a ndma r k
a nd i s f r e que nt l y i ndi s t i nc t . I t l i es s l i gh t l y po s t e r o -
me di a l t o t h e ge ni c ul a t e ga ngl i o n. Aga i n t h e r e t r a c t or
b l a de i s c o nt i nua l l y a dv a nc e d t o pr o v i de ne e de d
r e t r a c t i o n a s t h e dur a l e l e v a t i o n c o nt i nue s me di a l l y .
I mpo r t a nt s ur f a c e l a ndma r ks t ha t a i d o r i e nt a t i o n
h a v e n o w b e e n i de nt i f i e d.
Re mo v a l o f b o n e a nd e x po s ur e o f t h e f aci al ne r v e
i s n o w b e g u n . A l a r ge d i a mo n d b ur wi t h s uc t i o n
i r r i ga t i on ( t o pr e v e nt h e a t t r a ns f e r t o t he unde r l y i ng
f aci al ne r v e a nd s t r uc t ur e s ) i s us e d i ni t i a l l y. Bo ne
r e mo v a l i s b e g u n a t t h e f aci a) h i a t us a nd c o nt i nue d
a s h o r t di s t a nc e po s t e r i o r l y , f o l l o wi ng t h e gr e a t e r
s upe r f i c i a l pe t r o s a l ne r v e t o t h e ge ni c ul a t e ga ngl i o n
( Fi g. 1 8 - 5 / 1 ) . He r e t he f aci al ne r v e r uns me di a l l y
t o wa r d t h e i nt e r na l a udi t o r y me a t us . I mme di a t e l y
me di a l t o t h e ge ni c ul a t e ga ngl i o n, a s ma l l d i a mo n d
b ur i s us e d, s i nc e o nl y a f e w mi l l i me t e r s s e pa r a t e t h e
a mpul l a o f t h e s upe r i o r s e mi c i r c ul a r c a na l ( po s t e r i o r )
f r om t h e c o c h l e a ( a nt e r i o r ) . T h e facial ne r v e r uns
t h r o ugh t h i s s ma l l s pa c e . Bo n e r e mo v a l i s c o nt i nue d
me di a l l y t o ful l y e x po s e t h e l a b y r i nt h i ne s e g me n t o f
t h e facial ne r v e ; t hi s a f f or ds mo r e r o o m, s i nc e t he
pl a ne of t h e s upe r i o r s e mi c i r c ul a r c a na l r uns i n a 4 5 -
t o 6 0- de g r e e a ng l e po s t e r i o r l y f r om t h e a mpul l a .
32 4 I nf r a t e mpo r a l Fa c i a l Ne r v e S ur g e r y
Bo n e i s t h i nne d a r o und a ppr o x i ma t e l y 5 0 % o f t he
facial ne r v e . T h e e ggs h e l l - t h i n b o n e ma y t h e n b e
r e mo v e d wi t h a h o o k or bl unt i ns t r ume nt . It i s not
ne c e s s a r y t o e x p o s e t he f aci al ne r v e a l o ng t h e e nt i r e
l e ngt h o f t h e i nt e r na l a udi t o r y c a na l . Me di a l di s s e c -
t i on t o t h e na r r o we s t po i nt of t h e c a na l us ua l l y
c o ns t i t ut e s a de qua t e d e c o mp r e s s i o n . He r e c e r e b r o -
s pi na l f l ui d f l ow wil l be e n c o un t e r e d upo n e nt e r i ng
t he i nt e r na l a udi t o r y c a na l .
Th e f aci a] ne r v e i s t h e n f ni l v e x po s e d f r om t he
ge ni c ul a t e ga ngl i o n di s t a l l y t o t h e t y mpa ni c s e g me nt
up t o t h e c o c h l e a r i f o r m pr o c e s s ( Fi g. 1 8 - 5 B ) . ( Th i s i s
e a s i l y pe r f o r me d t h r o ugh t h e t e gme nt a l de f e c t c r e -
a t e d pr e v i o us l y . ) Ca r e mus t be t a ke n not t o i nj ur e
t he ma l l e us h e a d o r o t h e r o s s i c l e s i n o r de r t o pr e ve nt
s e ns o r i ne ur a l h e a r i ng l o s s . O p e n i n g t h e f aci al ne r v e
s h e a t h (if de s i r e d) ma y b e a c c o mp l i s h e d b y e x t e ndi ng
t he o pe ni ng f r om t h e t y mpa ni c s e g me n t t o t he
l a b y r i nt h i ne s e g me n t ( Fi g. I 8 - 5 C) .
T h e de f e c t i n t h e i nt e r na l a udi t o r y c a na l i s c l o s e s
wi t h a t e mpo r a l mus c l e pl ug a nd t h e t e mpo r a l l o b
i s a l l o we d t o r e - e x pa nd. T h e b o n e f l ap i s t h e n r epoV
s i t i o ne d a nd t h e wo u n d i s c l o s e d i n l a y e r s t e mpo r ; 1
mus c l e , s u b c u t a n e o u s t i s s ue , a nd s ki n. Us ua l l y n.*
e xt e r na l dr a i na ge i s us e d. A s t e r i l e dr e s s i ng i s ap
pl i e d.
Pertinent Histopathology
F 1 CUKE 1 8 - 6
Th i s pa t i e nt de v e l o pe d a f aci al pa r a l y s i s di a gno s e s
i ni t i al l y a s Be l l ' s pa l s y . An uns uc c e s s f ul s ur gi c t
d e c o mp r e s s i o n wa s pe r f o r me d. T h e s e c t i o n show%
t umo r i nv o l v e me nt o f t h e f aci al ne r v e ( me t a s t a t i c
c a r c i no ma o f t h e pr o s t a t e ) .
FIGURE 18-6.
CHAPTER 19
Tumors of the
Middle and Inner Ear
T u mo r s o f t h e mi ddl e a nd i nne r e a r i nc l ude gl o -
mu s t umo r s a nd a c o us t i c n e ur o ma s . G l o mu s t umo r s ,
o r pr i ma r y v a s c ul a r t umo r s o f t h e mi ddl e e a r , a r e
c l a s s i f i e d a c c o r di ng t o t h e i r l o c a t i o n a nd s i ze . G l o mu s
t y mp a n i c u m t umo r s a r e l i mi t e d t o t h e mi ddl e e a r
a nd ma s t o i d; g l o mu s j ugul a r e t umo r s i nv o l v e t h e
j ugul a r b ul b , mi ddl e e a r , a nd b a s e o f t h e s kul l . Th i s
c h a pt e r de s c r i b e s t h r e e s ur gi c a l a p p r o a c h e s t o gl o-
mus t umo r s b a s e d o n t h e i r s i ze . S ma l l a nd l ar ge
g l o mu s t y mp a n i c u m t umo r s a r e di s c us s e d, a s wel l
a s g l o mu s j ugul a r e t umo r s . T h e c h a pt e r a l s o de -
s c r i b e s a t r a ns l a b y r i nt h i ne a ppr o a c h for a c o us t i c ne u-
r o ma s
Glomus Tympanicum Tumors
Highlights
1. Ac c ur a t e pr e o pe r a t i v e a s s e s s me n t o f t h e t umo r
i s e s s e nt i a l t o e n s ur e t ha t t he t umo r i s l i mi t e d t o t h e
mi ddl e e a r o r ma s t o i d.
2. If a g l o mu s t umo r i s l i mi t e d t o t h e p r o mo n t o r y
a nd al l of its b o r de r s c a n be s e e n by a t r a ns c a na l
a ppr o a c h , a n e x pl o r a t o r y t y mp a n o t o my o r e nda ur a l
a ppr o a c h ma y b e us e d.
3 . Wh e n t h e e nt i r e c i r c umf e r e nc e o f t umo r c a nno t
be vi s ua l i ze d by a t r a ns c a na l a ppr o a c h a nd pr e o p-
e r a t i ve a s s e s s me n t s h o ws no i nv o l v e me nt o f t h e
j ugul a r bul b, a n e x t e n d e d f aci al r e c e s s a ppr o a c h i s
us e d.
Smal l Gl omus Tympani cum Tumor s
An e x pl o r a t o r y t y mp a n o t o my a ppr o a c h i s us e d t o
e x po s e t hi s t umo r , i f al l of its b o r de r s c a n be vi s ua l -
i ze d t h r o ugh a t r a ns c a na l a ppr o a c h ( Fi g. 1 9 - 1 / 1 ) . I f
ne e de d, e ndur a l i nc i s i o ns a l s o ma y be us e d t o a i d i n
e x po s ur e ( s e e Ch a pt e r 7 ) . Of t e n i t i s us e f ul t o e l e v a t e
t h e t y mp a n i c me mb r a n e of f t he ma l l e us ( us i ng a
s h a r p kni f e o r pi c k) t o i nc r e a s e e x po s ur e .
Wh e n a de qua t e e x po s ur e i s o b t a i ne d, r e mo v a l o f
t he t umo r i s b e gun. It i s i mpo r t a nt t o r e a l i ze t hat
b l e e di ng ma y b e pr o f us e a nd ne c e s s i t a t e s wo r ki ng
qui c kl y a nd e f f e c t i ve l y. To pi c a l Adr e na l i ne a nd S ur -
gi cel or a s i mi l a r pa c ki ng ma y a l s o be us e d dur i ng
t he pr o c e dur e a s ne e de d. An i nc i s i o n i s ma d e i n t h e
mu c o u s me mb r a n e a t t h e pe r i ph e r y o f t h e t umo r .
Th e t umo r i s t h e n e l e v a t e d f r om t h e pr o mo nt o r y ,
mo b i l i zi ng all b o r de r s ( Fi g. 1 9 - 1 8 ) . Oc c a s i o na l l y , a
ma j o r f e e di ng a r t e r y i s s e e n; i t ma y be f ul gur a t e d
( c a r e mus t be t a ke n no t t o t o uc h t h e pr o mo nt o r y
wi t h t h e c ur r e nt ) . T h e t umo r i s t h e n r e mo v e d i nt act
( Fi g. 1 9 - 1 C) . Aga i n, i f b l e e di ng i s br i s k t he s ur ge o n
mus t wo r k qui c kl y ( wi t h l a r ge s uc t i o n a nd pa c ki ng
a s n e e d e d ) t o r e mo v e t h e t umo r t ot al l y; t he b l e e di ng
wil l be e a s y t o c o nt r o l o n c e t h e t umo r h a s b e e n
r e mo v e d. Cl o s ur e a nd pa c ki ng a r e t h e s a me a s for
t h e s t a nda r d a p p r o a c h e s
Larger Gl omus Tympani cum Tumor s
I f t h e e nt i r e b o r de r o f t h e t umo r c a nno t be vi s u-
a l i ze d a nd r a di o l o gi c s t udi e s s h o w t ha t i t i s l i mi t e d
t o t h e mi ddl e e a r , a po s t e r i o r a ppr o a c h i s us e d. Th i s
FIGURI-: I ' M
T u mo r s o f t h e Mi ddl e a nd I nne r Ea r 327
a l l o ws vi s ua l i za t i o n o f t h e s upe r i o r , po s t e r i o r , a n d
mo s t i mpo r t a nt l y , t o e ns ur e t hat t h e r e i s no j ugul a r
bul b i nv o l v e me nt i nf e r i o r b o r de r s . A t r a ns c a na l
t y mp a n o t o my for a nt e r i o r b o r de r e x po s ur e ma y b e
us e d i f t h e r e i s a ny que s t i o n of c a r o t i d a r t e r y i nvo l ve -
me nt .
T h e po s t e r i o r a ppr o a c h i nc l ude s a po s t a ur i c ul a r
i nc i s i o n, c o mp l e t e ma s t o i de c t o my , a nd o pe ni ng o f
t he f aci al r e c e s s . T h e f aci al r e c e s s i s t h e n e x t e nde d
i nt e r i or l y t o e x p o s e t h e h y p o t y mp a n u m; t h i s r e qui r e s
s a c r i f i c i ng t h e c h o r da t y mpa ni . T h e b o r de r s o f t h e
e x t e nde d f aci al r e c e s s a r e t h e f i br o us a nnul us l at -
er al l y a n d t h e f a l l opi a n c a na l me di a l l y . T h e r e c e s s i s
c a r r i e d i nf e r i or l y unt i l i t i s f l us h wi t h t h e f l oor of t he
mi ddl e e a r . At t h i s po i nt , t h e i nf e r i or b o r de r o f t h e
t umo r i s s e e n i n t h e h y p o t y mp a n u m. Wi t h a bl unt
pr o be , t h e b o n y wa l l o f t h e h y p o t y mp a n u m ma y b e
pa l pa t e d t o e ns ur e b o n e i nt e gr i t y a nd no ni nv o l v e -
me nt o f t h e j ugul a r b ul b . T h e r e t r of a c i a l ai r c e l l s
s h o ul d a l s o b e o p e n e d s i nc e l a r ge r t umo r s of t e n
e x t e nd i nt o t h i s s pa c e ( t h i s a ppr o a c h a l l o ws go o d
a c c e s s t o t h i s a r e a ) ( Fi g. 1 9 - I D ) . S upe r i o r l y , i f t h e
t umo r i nv o l v e s t h e o s s i c l e s , t h e i nc udo s t a pe di a l j o i nt
ma y ne e d t o b e di s c o nne c t e d a nd t h e i nc us r e mo v e d
t o a l l o w s a f e r e mo v a l o f t h e t umo r . An e x pl o r a t o r y
t y mp a n o t o my ma y b e pe r f o r me d c o nc ur r e nt l y t o
h e l p e x p o s e a s upe r i o r l y l o c a t e d t umo r . Aga i n, e l e -
va t i ng t h e t y mpa ni c me mb r a n e of f t h e ma l l e us wi l l
e n h a n c e e x po s ur e ( a nd a l s o a l l o w de l i ne a t i o n o f t he
t umo r ' s a nt e r i o r b o r de r ) .
At t h i s po i nt , t u mo r r e mo v a l ma y c o mme n c e .
Aga i n, b r i s k b l e e di ng ne c e s s i t a t e s r a pi d a nd e f f i c i e nt
wo r k. I f po s s i b l e , t h e t umo r i s f r e e d i n its e nt i r e t y
a nd r e mo v e d ( Fi g. 191E) . Us ua l l y t h e t umo r i s t oo
l a r ge t o pe r mi t t h i s , a n d i t i s r e mo v e d i n pi e c e s af t er
f r e e i ng o f its pe r i ph e r y . Wh e n br i s k b l e e di ng i s
e nc o unt e r e d, t hi s a r e a ma y b e pa c ke d a n d a t t e nt i o n
di r e c t e d e l s e wh e r e . Ca r e mus t be t a ke n t o l o o k for
de h i s c e nc e o r i nv o l v e me nt o f t h e j ugul a r bul b i nf e-
r i o r l y a nd o f t h e c a r o t i d a r t e r y a nt e r i o r l y .
Wh e n c o mpl e t e r e mo v a l i s a c c o mpl i s h e d, o s s i c ul a r
r e c o ns t r uc t i o n i s pe r f o r me d (if ne e de d) . T h e i nc i s i o ns
ar e c l o s e d i n t h e us ua l ma nne r .
Infralabyrinthine, Infratemporal
Approach for Glomus Jugulare
Tumors
Highlights
1. A c o mpl e t e ma s t o i d e c t o my ( ma s t o i d tip r e-
mo v e d ) i s pe r f o r me d wi t h a n e x t e nde d f aci al r e c e s s
2 . T h e b o n y e x t e r na l a udi t o r y c a na l , t y mpa ni c
me mb r a n e , i nc us , a nd ma l l e us a r e r e mo v e d
3. T h e f aci al ne r v e i s mo b i l i z e d a nd t r a ns po s e d
a nt e r i o r l y .
4. T h e j ugul a r ve i n i s i de nt i f i e d i n t h e ne c k a nd
c o nt r o l l e d i nf e r i or t o t umo r .
5. T h e s i gmo i d s i nus i s c o nt r o l l e d di s t a l t o t umo r .
6. T h e t umo r i s r e mo v e d i n a n a nt e r o i nf e r i o r - t o -
s upe r i o r di r e c t i o n, wi t h c o ns t a nt a t t e nt i o n gi v e n t o
t he i nt e r na l c a r o t i d a r t e r y a nt e r i o r l y .
7. A s ma l l e r i nt r a c r a ni a l e x t e ns i o n ma y be h a n-
dl e d wi t h t h i s a ppr o a c h .
8. T h e e x t e r na l a udi t o r y c a na l i s s ut ur e d c l o s e d
( c r e a t i ng a bl i nd po uc h ) ; wi t h a dur a l de f e c t , t h e
c a vi t y i s pa c ke d wi t h fat or mus c l e .
Pitfalls
1. I nj ur i ng t h e i nt e r na l c a r ot i d a r t e r y ( mo s t
c o mmo n l y i nf r a t e mpo r a l l y a t t h e c a r o t i c o t y mpa ni c
b r a nc h ) .
2. Ca u s i n g de f i c i t s o r i nj ur i e s t o t h e ni nt h , t e nt h ,
e l e v e nt h , a n d t we l f t h c r a ni a l ne r v e s , wi t h a s s o c i a t e d
po s t o pe r a t i v e pr o b l e ms .
3. Fa i l i ng t o r e c o gni ze a s s o c i a t e d l e s i o ns ( s uc h a s
p h e o c h r o mo c y t o ma s , c a r o t i d b o dy t umo r s , a nd s o
o n) .
4. Ce r e b r o s pi na l f l ui d l e a ks .
Procedure
Af t e r pr e o pe r a t i v e e v a l ua t i o n h a s e s t a b l i s h e d j ug-
ul ar b ul b i nv o l v e me nt , a mo r e e x t e ns i v e a ppr o a c h t o
t h e s kul l b a s e i s i ndi c a t e d f or t ot al t umo r r e mo v a l
wi t h t h e s ma l l e s t r i s k o f mo r b i di t y o r mo r t a l i t y .
T h e pa t i e nt i s pl a c e d i n t h e s upi ne po s i t i o n. T h e
i nv o l v e d s i de i s s h a v e d, pr e pa r e d, a nd dr a pe d i n t he
us ua l s t e r i l e ma nne r ; t h e s ur gi c a l f i e l d i nc l ude s t h e
i ps i l a t e r a l ne c k. A po s t a ur i c ul a r i nc i s i o n i s ma d e i n
a c ur v i l i ne a r f a s h i o n f o l l o wi ng t h e po s t a ur i c ul a r
c r e a s e ( s l i gh t l y mo r e po s t e r i o r t h a n f or a s t a nda r d
ma s t o i de c t o my ) ( Fi g. 1 9 - 2 / 1 ) . T h e i nf e r i or l i mb o f t he
i nc i s i o n i s c a r r i e d i nt o t h e ne c k, e x t e ndi ng a l o ng t he
a nt e r i o r b o r de r o f t h e s t e r no c l e i do ma s t o i d mus c l e .
A c o mp l e t e ma s t o i de c t o my i s pe r f o r me d, de l i ne -
a t i ng t h e t e g me n, s i gmo i d s i nus ( e x po s ur e i s e x-
t e nde d po s t e r i o r l y t o t h e s i nus ) , a nt r um, a nd b o ny
l a by r i nt h . T h e ma s t o i d t i p i s c o mpl e t e l y o p e n e d a nd
r e mo v e d. T h e e xt e r na l a udi t o r y c a na l i s t r a ns e c t e d
wi t h a s c a l pe l at t h e l e ve l of t h e c a r t i l a gi no us - b o ny
j unc t i o n a nd t h e n b r o ug h t f o r wa r d wi t h r e t r a c t or s .
Temporomandibular
T u mo r s o f t h e Mi ddl e a nd I nne r Ea r 32 9
T h e c a na l i s t h i nne d a nd a n e x t e nde d facial r e c e s s i s
o p e n e d t o t h e f l oor o f t h e h y p o t y mp a n u m
T h e i nc udo s t a pe di a l j oi nt i s di s l o c a t e d wi t h a j oi nt
kni f e a nd t h e i nc us i s r e mo v e d. T h e t h i nne d po s t e r i o r
e x t e r na l a udi t o r y c a na l i s t h e n r e mo v e d, a s wel l a s
t he t y mpa ni c me mb r a n e , ma l l e us , a nd s ki n o f t h e
b o ny e x t e r na l a udi t o r y c a na l . T h e b o n y a nt e r i o r a n d
i nf e r i or c a na l i s a l s o r e mo v e d wi t h a d i a mo n d b ur
wh i l e pr e s e r v i ng t h e pe r i o s t e um ( t h i s a i ds a nt e r i o r
e x po s ur e a nd r e t r a c t i o n) . T h e s t a pe s i s l eft i nt a c t .
Wi t h a d i a mo n d bur , t h e b o ny f a l l opi a n c a na l i s
r e mo v e d f r om t h e ge ni c ul a t e ga ngl i o n t o t h e s t yl o-
ma s t o i d f o r a me n. T h e facial ne r v e i s mo b i l i z e d a nd
t r a ns po s e d a nt e r i o r l y . A sof t t i s s ue s l i ng ma y be
c r e a t e d t o h e l p h o l d t h e ne r v e o ut o f t h e f i el d. Wi t h
t h e f aci al ne r v e n o w l o c a t e d a nt e r i o r l y , a n o b s t r uc t e d
v i e w o f t h e j ugul a r b ul b a nd t umo r i s po s s i b l e ( Fi g.
1 9 - 2 8 , C) . Wi t h l a r ge c e r e b e l l a r r e t r a c t o r s , t h e ma n-
di bl e c o n d y l e ma y b e di s l o c a t e d a n d r e t r a c t e d a nt e -
r i or l y f or a n a ddi t i o na l 1- t o 2 - c m e x po s ur e t o t h e
i nf r at ef r t por a! r e gi o n. Ca r e mus t be t a ke n not t o
i nj ur e t h e t r a ns po s e d f aci al ne r v e wi t h t h e r e t r a c t o r s .
I f ne c e s s a r y , t h e ma ndi b l e r a mus ma y b e t r a ns e c t e d.
D e c o mp r e s s i o n o f t h e s i gmo i d s i nus mus t b e c o m-
pl e t e d t o a l l o w f or di s t al c o nt r o l o f v e n o u s b l e e di ng.
Bo ne d e c o mp r e s s i o n i s pe r f o r me d f r o m j us t b e l o w
t h e s i no dur a l a ng l e a nd c a r r i e d i nt e r i o r l y t o t h e
j ugul a r b ul b ( or t umo r ) . I nt e r i or l y, t h e b o n e o v e r t h e
po s t e r i o r f os s a a l s o i s r e mo v e d . T h e t umo r c a n n o w
be c l e a r l y vi s ua l i ze d f r om t he j ugul a r b ul b , wi t h its
e x t e ns i o n i nt o t he mi ddl e e a r o r ma s t o i d
Th e ne c k i s n o w e nt e r e d t o obt a i n pr o xi ma l e x -
po s ur e a nd c o nt r o l o f t h e j ugul a r ve i n a nd c a r ot i d
a r t e r y. I f not a l r e a dy a c c o mpl i s h e d, t h e ma s t o i d
pr o c e s s a t t a c h me nt s o f t h e s t e r no c l e i do ma s t o i d a nd
di ga s t r i c mus c l e s a r e s h a r pl v di s s e c t e d a nd r e f l e c t e d
a nt e r i o r l v. T h e l at er al pr o c e s s o f t h e first c e r vi c a l
ve r t e br a i s pa l pa t e d. J us t i nf e r i or t o t hi s pr o c e s s i s
t he e l e v e nt h ne r v e . By f o l l o wi ng t h i s ne r v e f o r wa r d,
t he j ugul a r ve i n i s f o und. T h e r e l a t i o ns h i p o f t h e
e l e v e nt h ne r v e t o t h e ve i n va r i e s ; mo s t c o mmo n l y i t
r uns l a t e r a l l y t o t h e j ugul a r ve i n, but o c c a s i o na l l y i t
r uns me di a l l y . T h e ve i n i s i s o l a t e d, t i es a r e pl a c e d,
a nd t h e ve i n i s l i ga t e d me di a l t o t h e t umo r f or
pr o xi ma l c o nt r o l . Di s t a l c o nt r o l i s a c c o mpl i s h e d a t
t he d e c o mp r e s s e d s i gmo i d s i nus . Us ua l l y pa c ki ng i s
us e d e i t h e r e x t r a l umi na l l y o r i nt r a l umi na l l y af t er a n
o pe ni ng i s ma d e i n t h e l ume n ( Fi g. 1 9 - 3 / 1 ) . T h e
c a r ot i d a r t e r y i s i de nt i f i e d a nd i s o l a t e d i n c a s e i nj ur y
o c c ur s , r e qui r i ng c o nt r o l o f b l e e di ng.
Wi t h t ot al e x po s ur e no w a c c o mpl i s h e d, t umo r
r e mo v a l i s b e g un. T h e s upe r i o r b o r de r i s mo b i l i ze d
f r om a ga i ns t t he b o n y l a by r i nt h . Ant e r i o r l y t h e t umo r
i s mo b i l i z e d unl e s s t h e r e i s i nv o l v e me nt wi t h a n d
a dh e r e nc e t o t h e c a r o t i d a r t e r y . R e mo v a l b e g i ns
i nf e r i or l y wh e r e t h e j ug ul a r ve i n wa s t r a ns e c t e d.
Di s s e c t i o n b e g i ns h e r e a n d c o nt i nue s s upe r i o r l y ,
de v e l o pi ng a nd f o l l o wi ng a pl a ne b e t we e n t h e t umo r
a nd c a r o t i d. Ant e r i o r l y t h e c a r o t i d a r t e r y of t e n i s
i nv o l v e d wi t h l a r ge r t umo r s a nd pr e s e nt s a f or mi -
da bl e t a s k t o s a f e l y mo b i l i z e a nd s e pa r a t e t h e t umo r .
I nf r a t e mpo r a l l y , wh e r e t h e c a r o t i d t ur ns t o i t s h or i -
zo nt a l c o ur s e , a s ma l l b r a nc h ( c a r o t i c o t y mpa ni c
b r a nc h ) of t e n s uppl i e s t h e t umo r a nd pr e s e nt s a
pa r t i c ul a r l y t r o ub l e s o me pr o b l e m. I de a l l y i t i s di s -
s e c t e d a s h o r t di s t a nc e f r o m t he c a r o t i d l e s i o n t o
a f f or d a n o ppo r t uni t y t o s a f e l y c o nt r o l it; h o we v e r ,
i t ma y be a v ul s e d, i nj ur i ng t h e c a r ot i d l u me n a t a
poi nt wh e r e di s t al c o nt r o l of b l e e di ng i s di f f i cul t . I f
c a r o t i d i nj ur y o c c ur s , r e pa i r o f t h e l u me n wi t h a f i ne
a r t e r i a l s ut ur e (if pr o x i ma l a nd di s t al c o nt r o l c a n be
o b t a i ne d) s h o ul d b e a t t e mpt e d. I f t h i s c a nno t b e
a c c o mpl i s h e d, pa c ki ng o f t h e a r e a wi l l c o nt r o l t h e
b l e e di ng ( wi t h its a c c o mp a n y i n g r i s k o f s e v e r e mo r -
bi di t y o r mo r t a l i t y ) .
As t h e t umo r di s s e c t i o n c o nt i nue s s upe r i o r l y , t h e
ni nt h , t e nt h , e l e v e nt h , a nd t we l f t h c r a ni a l ne r v e s
wi l l b e e n c o un t e r e d . An a t t e mpt s h o ul d b e ma d e t o
i de nt i f y t h e s e ne r v e s a n d pr e s e r v e t h e m i f po s s i b l e .
Of t e n t h e y a r e i nt i ma t e l y i nv o l v e d wi t h t h e t umo r
ma s s ( or a r e di f f i cul t t o i de nt i f y ) , a nd a r e s a c r i f i c e d
o r i nj ur e d.
At t h e l e ve l o f t he j ugul a r bul b a nd s i gmo i d s i nus ,
t he me di a l wa l l of t h e s i nus i s di s s e c t e d f r om t h e
t umo r ma s s , l e a v i ng t h e dur a i nt a c t ( Fi g. 1 9 - 3 8 ) .
P r o f us e b l e e di ng i s e nc o unt e r e d i n t h e a r e a of t h e
bul b f r om t h e i nf e r i or pe t r o s a l s i nus , wh i c h e mpt i e s
i nt o t h e b ul b o n i t s me di a l s i de . P a c ki ng i s ne e de d
t o c o nt r o l t h i s b l e e di ng, s i nc e t h e r e i s no wa y t o
o bt a i n c o nt r o l o f t hi s s i nus .
F o l l o wi ng di s s e c t i o n a nt e r i o r l y a nd po s t e r i o r l y ,
t h e t umo r ma s s i s h i ng e d i n t h e h y p o t y mp a n i c ,
i nf r a l a b y r i nt h i ne a r e a a nd i s r e mo v e d c a r e f ul l y. I f
i nt r a c r a ni a l e x t e ns i o n i s pr e s e nt , a c e r e b r o s pi na l fl uid
l e a k wi l l b e e nc o unt e r e d upo n t umo r ma ni pul a t i o n.
T u mo r bul k ma y b e r e mo v e d t o i mpr o v e vi s ua l i za -
t i on, a nd t h e dur a ma y b e o p e n e d wi de r t o e n h a n c e
po s t e r i o r f os s a e x po s ur e . A s ma l l i nt r a c r a ni a l e x t e n-
s i on ma y t h e n b e c a r e f ul l y r e mo v e d , pr o t e c t i ng a nd
pr e s e r v i ng i nt r a c r a ni a l s t r uc t ur e s ( a nt e r o i nf e r i o r a nd
po s t e r o i nf e r i o r c e r e b e l l a r a r t e r i e s , b r a i ns t e m, c r a ni a l
ne r v e s , a n d s o o n) .
Af t e r t h e t umo r h a s b e e n c o mpl e t e l y r e mo v e d,
t h e dur a l de f e c t i s c l o s e d wi t h e i t h e r f r ee a b do mi na l
fat or a mu s c l e pl ug. T h e t r a ns po s e d f aci al ne r v e i s
r e l e a s e d a nd pl a c e d i n a t e ns i o n- f r e e po s i t i o n. T h e
t r a ns e c t e d e x t e r na l a udi t o r y c a na l i s e v e r t e d a nd
c l o s e d wi t h a p e r ma n e n t s ut ur e ( r e s ul t i ng i n a bl i nd
po uc h ) . T h e po s t a ur i c ul a r i nc i s i o n i s c l o s e d i n l a ye r s
a nd dr e s s i ngs a r e a ppl i e d. Oc c a s i o na l l y for l a r ge
330 T u mo r s o f t h e Mi ddl e a nd I nne r t a r
J ugular vein
Sigmoid sinus packed
Sigmoid sinus
(medial wall)
FIGURE ] 9 - 3
T u mo r s o f t he Mi ddl e a nd I nne r Ea r 331
dur al de f e c t s , l umb a r dr a i ns a r e pl a c e d a t t h e e nd of
t he pr o c e dur e t o h e l p pr e v e nt c e r e b r o s pi na l f l ui d
l e a ka ge .
Translabyrinthine Approach for
Acoustic Neuromas
Aim
Wi d e e x po s ur e o f t h e t umo r wi t h e a r l y i de nt i f i c a -
t i on of t h e f aci al ne r v e , a l l o wi ng f or t ot al e xc i s i o n of
t h e t umo r wi t h pr e s e r v a t i o n o f t h e ne r ve .
Highlights
1. T h e i nc i s i o n i s mo r e po s t e r i o r t h a n t h e us ua l
po s t a ur i c ul a r i nc i s i on.
2. Dr i l l i ng i s do ne po s t e r i o r t o t he s i gmo i d s i nus
i n o r de r t o a l l o w po s t e r i o r de c o mpr e s s i o n ( r e t r a c t i o n)
of it.
3. T h e i nt e r na l a udi t o r y c a na l i s i de nt i f i e d a nd t h e
po s t e r i o r h a l f o f t h e b o n e i s r e mo v e d.
4 T h e f aci al ne r v e i s i de nt i f i e d at Bi l l ' s ba r as i t
b e gi ns its l a b y r i nt h i ne c o ur s e .
5. T h e s upe r i o r a nd i nf e r i or ve s t i bul a r ne r v e s a nd
t he c o c h l e a r ne r v e a r e a v ul s e d.
6. T h e t umo r i s r e mo v e d a wa y f r om t h e facial
ne r ve .
Pitfalls
1. Fa i l i ng t o a de qua t e l y de c o mpr e s s t he s i gmo i d
s i nus a nd t o r e mo v e b o ne f r om t he po s t e r i o r f os s a
dur a .
2. Fa i l i ng t o o pe n t he i nt e r na l a udi t o r y c a na l
wi de l y for full e x po s ur e of t h e t umo r .
3. Fa i l i ng t o po s i t i ve l y i de nt i f y t he f aci al ne r v e
be f or e a v ul s i ng ne r v e s .
4. S t r e t c h i ng ( or c o mpl e t e l y t r a ns e c t i ng) t he facial
ne r ve dur i ng t umo r r e mo v a l .
5. I nc o mpl e t e l y r e mo v i ng t he t umo r .
Procedure
For t h i s a ppr o a c h t h e pa t i e nt l i es s upi ne . Pr e pa -
r at i on a nd dr a pi ng a r e t he s a me a s for a s t a nda r d
e a r pr o c e dur e wi t h t he e x c e pt i o n of a l a r ge r h e a d
s h a v e . By pl a c i ng t he pa t i e nt ' s h e a d a t t h e f oot of
t he t a bl e , t h e s ur ge o n wil l h a v e r o o m f or h i s or h e r
l e gs unde r t h e t a bl e a nd b e mo r e c o mf o r t a b l e . T h e
pa t i e nt mus t be s e c ur e l y s t r a ppe d t o t h e t a bl e , s i nc e
f r e que nt s i de - t o - s i de r ot a t i on i s ne e de d.
T h e po s t a ur i c ul a r i nc i s i o n i s de s i g ne d a s us ua l but
l o c a t e d f a r t h e r po s t e r i o r l y , t o a l l o w dr i l l i ng po s t e r i o r
t o t he s i gmo i d s i nus ( Fi g. 1 9 - 4 / 1 ) . Th i s i s e s s e nt i a l
f or c o mpl e t e de c o mpr e s s i o n o f t h e s i gmo i d s i nus a nd
o pt i ma l l at er vi s ua l i za t i on i nt o t he c e r e b e l l o po nt i ne
a ngl e ; i f a n e r r or i s ma de , i t s h o ul d be ma d e i n
ma ki ng t h e i nc i s i o n t oo far po s t e r i o r . T h e i nc i s i o n
l i es 1 t o l '/2 i n ( i t its mo s t po s t e r i o r po s i t i o n) b e h i nd
t h e a ur i c l e a nd r uns i n an e x t e nde d C s h a pe . It i s
c a r r i e d t h r o ugh t h e pe r i o s t e um o f t h e ma s t o i d c o r t e x,
a v o i di ng t h e t e mpo r a l mus c l e s upe r i o r l y , T h e per i -
o s t e um i s t h e n e l e va t e d a nd t h e e a r h e l d f o r wa r d
wi t h c e r e be l l a r r e t r a c t or s . Re t r a c t o r s pl a c e d i n t h e
s upe r i o r - t o - i nf e r i o r di r e c t i o n wi l l h o l d t h e t e mpo r a l
mus c l e out o f t h e s ur gi c a l f i e l d.
Us i ng t h e l a r ge s t c ut t i ng b ur a nd s uc t i o n i r r i ga-
t i on, dr i l l i ng i s b e gun. T h e ma s t o i d c o r t e x i s r e mo v e d
as i n a r o ut i ne ma s t o i de c t o my . Ca r e i s t a ke n t o
s a uc e r i ze t h e e dg e s a nd ke e p t h e l a t e r a l mo s t o pe ni ng
a s wi de a s po s s i bl e . I n t h i s pr o c e dur e , i t i s i mpo r t a nt
t o e x t e nd t h e dr i l l i ng po s t e r i o r t o t h e s i gmo i d s i nus .
Th i s b o ne r e mo v a l i s c o mpl e t e d d o wn t o t h e po s t e -
r i or f os s a dur a . Fo r l a r ge t umo r s , t h e po s t e r i o r di s -
s e c t i o n ma y e x t e nd 1 t o I
1
/ ; i n b e h i nd t h e s i gmo i d
s i nus . Fi na l b o n e r e mo va l i s a c c o mpl i s h e d l a t e r wi t h
t h e di a mo nd b ur t o a voi d t e a r i ng o f t he dur a a nd
s ub s e que nt c e r e be l l a r h e r ni a t i o n. I n t hi s a r e a e mi s -
s a r y v e i ns a r e f o und r unni ng f r om t h e s i gmo i d s i nus
t o t h e c o r t e x; o c c a s i o na l l y qui t e l a r ge , t h e y ma y be a
s o ur c e o f t r o ub l e s o me b l e e di ng a nd mus t be a p-
pr o a c h e d c a ut i o us l v.
At t hi s poi nt t h e o pe r a t i ng mi c r o s c o pe i s br o ugh t
i nt o t h e f i el d. T h e ma s t o i de c t o my i s c o mpl e t e d a s
de s c r i b e d i n pr e v i o us c h a pt e r s , af t er wh i c h s t e p t h e
s ur ge o n s h o ul d be a bl e t o i de nt i f y de f i ni t e l y t he
h o r i zo nt a l a nd po s t e r i o r s e mi c i r c ul a r c a na l s . Wi t h
t hi s ba s i c l a ndma r k, t he po s i t i o ns of t he i nc us , facial
ne r v e , a nd po s t e r i o r s e mi c i r c ul a r c a na l a r e k n o wn
e v e n i f t h e y a r e no t yet ful l y s e e n. Bo ne o v e r t he
t e gme n, s i gmo i d s i nus , po s t e r i o r f os s a , s i no dur a l
a ngl e , a nd e xt e r na l a udi t o r y c a na l i s t h i nne d t o a l l o w
full e x po s ur e a nd de e pe r di s s e c t i o n. I f t he s i gmo i d
s i nus i s di s pl a c e d a nt e r i o r l y , i t ma y be d e c o mp r e s s e d
a t t h i s s t a ge ; i f i t i s po s s i bl e t o pe r f o r m t h e l a byr i n-
t h e c t o my no w, i t ma y be be t t e r t o de l a y t h e a c t ua l
de c o mpr e s s i o n. Th i s pr e v e nt s t h e pr o b l e m o f c e r e -
be l l a r h e r ni a t i o n i f t h e dur a i s i na dv e r t e nt l y o p e n e d
o r o f vi s i on b e i ng o bs t r uc t e d by pa c ki ng i f t h e s i nus
i s i nj ur e d.
T u mo r s o f t he Mi ddl e a nd I nne r Ea r 333
A ful l l a b y r i nt h e c t o my h a s b e e n di s c us s e d i n pr e-
v i o us c h a pt e r s . Di s s e c t i o n i s s t a r t e d i n t he a r e a of
t he c o mmo n c r us ( j us t a nt e r i o r t o t h e s i no dur a l
a ngl e ) ; t h i s i s t h e s a f e s t pl a c e t o b e gi n, s i nc e t he
facial ne r v e i s far a nt e r i o r . Di s s e c t i o n i s c o nt i nue d
me di a l l y a nd i nt e r i or l y unt i l e a c h c a na l i s f o und a nd
c o mpl e t e l y "dr i l l e d o ut . " R e me mb e r t o ke e p t he
s i no dur a l a ngl e c l e a n a nd wi de l y o pe n t o a l l o w for
ma x i mu m e x po s ur e l at er . T h e b o n e h e r e i s t h i nne d,
a nd t h e s upe r i o r pe t r o s a l s i nus i s s e e n a s i t r uns
f r om t h e s i gmo i d t o t h e pe t r o us a pe x ( Fi g. 1 9 - 4 B ) .
Th e po s t e r i o r c a na l i s e nc o unt e r e d f i r s t a nd f o l l o we d
a s i t c o ur s e s a nt e r o i nf e r i o r l y . I n a ppr o a c h i ng t h e
a mpul l a , be a wa r e t ha t t he facial ne r v e i s j us t l at er al
i n o r de r t o a vo i d i nj ur y t o it. T h e j ugul a r b ul b l i es
i nf er i or t o t he po s t e r i o r c a na l a nd r a r e l y ma y be s o
h i gh a s t o t o uc h t h e po s t e r i o r c a na l . By f ol l owi ng t h e
c o mmo n c r us me di a l l y , t h e s upe r i o r s e mi c i r c ul a r
c a na l c a n be e nt e r e d a nd t h e n f o l l o we d i n its a nt e r o -
s upe r i o r c o ur s e . R e me mb e r t hat t h i s c a na l l i es i n a
mu c h ' de e pe r ( me di a l ) pl a ne t h a n t h e o t h e r t wo
c a na l s . As t h e - a mpul l a o f t h e s upe r i o r c a na l i s e n-
t e r e d, it is left pa r t i a l l y i nt act to pr o vi de a l at er
l a ndma r k t o t he s upe r i o r ve s t i bul a r ne r v e a nd l a t e r a l -
mo s t e nd o f t h e i nt e r na l a udi t o r y c a na l . As t h e
di s s e c t i o n c o nt i nue s a nt e r i o r l y ( f o r wa r d) , t he l at er al
c a na l i s o pe ne d c o mpl e t e l y ; t h e s i de o f t h e c ut t i ng
bur ( no t t h e t i p) i s us e d, a l l o wi ng f or a s a f e r a ppr o a c h
wi t h be t t e r vi s ua l i za t i o n of t h e f aci al ne r ve . Us i ng
t he d i a mo n d bur , t h e f aci al ne r v e i s po s i t i ve l y i de n-
t i f i ed. Th i s ma r ks t h e a nt e r i o r l i mi t o f t h e di s s e c t i o n.
Ca r e f ul l y s ke l e t o ni zi ng t h e f aci al ne r v e a f f or ds a s
mu c h r o o m a s po s s i b l e f or full vi s ua l i za t i on of t he
ve s t i bul e a nd, l at er , t h e l at er al e nd o f t h e i nt e r na l
a udi t o r y c a na l .
T h e final s t e ps a r e t o ful l y o pe n t h e ve s t i bul e a nd
t o c o mpl e t e l y t hi n t he mi ddl e f os s a t c g me n, s i no -
dur a l a ngl e , a nd po s t e r i o r f os s a dur a t o t he l evel t hat
t he di s s e c t i o n h a s r e a c h e d. Th e di s s e c t i o n i s c a r r i e d
i nt e r i or l y t o i de nt i f y t he j ugul a r bul b; s e e n as a bl ui s h
di s c o l o r a t i o n t h r o ugh t h e b o ne , i t r e pr e s e nt s t he
i nf e r i or l i mi t of di s s e c t i o n. As t he di s s e c t i o n i s c a l l e d
i nt e r i or l y, t h e r e t r of a c i a l ai r c e l l s of t en a r e o pe ne d t o
e n h a n c e e x po s ur e . Al s o f o und i n t h i s a r e a i s t h e
ve s t i bul a r a que duc t a s i t r uns me di a l l y t o t h e po s t e -
r i or c a na l f r om t he e ndo l y mph a t i c s a c . T h e l a byr i n-
t h e c t o my h a s no w b e e n c o mpl e t e d.
I mme di a t e l y me di a l t o t h e ve s t i bul e l i es t he i nt e r -
nal a udi t o r y c a na l ( r e me mb e r t hat t h e me di a l wa l l o f
t he s upe r i o r c a na l a mpul l a i s t he l at er al wal l of t h i s
c a na l ) . At t h i s poi nt , t he s i gmo i d s i nus s h o ul d be
d e c o mp r e s s e d s o t hat i t c a n be r e t r a c t e d pos t e r i or l y,
t h i s pr o v i de s mo r e wo r ki ng a r e a , e s pe c i a l l y po s t e -
r i or l y at t h e b r a i ns t e m- t umo r j unc t i o n. A l a r ge di a-
mo n d b ur a nd c o ns t a nt i r r i ga t i on i s us e d t o t hi n t he
b o ne o v e r t h e e nt i r e s i nus . Fi na l b o ne r e mo v a l i s
a c c o mpl i s h e d wi t h t he d i a mo n d bur or a bl unt pi ck.
A t hi n i s l a nd of b o ne ( Bi l l ' s i s l a nd) i s l eft o v e r t h e
e x po s e d s i nus t o pr e v e nt i nj ur y f r om t h e s h a nk o f
t he bur wh e n de e pe r di s s e c t i o n i s r e s ume d. Bo n e
ma y b e r e mo v e d po s t e r i o r t o t h e s i nus e x po s i ng t h e
dur a a n d a l l o wi ng mo r e r e t r a c t i o n wi t h i nc r e a s e d
vi s ua l i za t i o n i nt o t he i nt e r na l a udi t o r y c a na l a nd
c e r e b e l l o po nt i ne a ngl e . T h e t h i nne d b o n e i s t h e n
r e mo v e d f r om t he po s t e r i o r f os s a me di a l t o t h e
s i gmo i d s i nus t o t h e l e ve l t h a t t he di s s e c t i o n h a s
r e a c h e d; t hi s i s do ne wi t h t h e di a mo nd bur , s uc t i o n,
a nd bl unt i ns t r ume nt s . Ca r e mus t be t a ke n no t t o
t ear t h e dur a ( t o pr e v e nt c e r e be l l a r h e r ni a t i o n a nd
a vo i d v e s s e l s ' t h a t ma y l ie i mme di a t e l y unde r ne a t h )
o r t o r upt ur e t h e s upe r i o r pe t r o s a l s i nus b e h i nd t h e
s i no dur a l a ngl e . Wi t h l a r ge t umo r s , t he wo r ki ng a r e a
i s i mpr o v e d r e mo v i ng b o ne f r om t h e po s t e r i o r
e nd of t he t e g me n, a l l o wi ng a be t t e r a ngl e f or i ns t r u-
me nt a t i o n.
Wi t h t h e s upe r i o r , i nf e r i or , a nd a nt e r i o r l i mi t s
no w we l l de f i ne d, full a t t e nt i o n i s gi ve n t o t h e
i nt e r na l a udi t o r y c a na l . T h e o b j e c t i v e i s t o obt a i n
1 8 0- de gr e e b o n e r e mo va l o f t h e po s t e r i o r h a l f o f t h e
c a na l . T h i s i s ne c e s s a r y f or full e x po s ur e a nd t o
pr e v e nt b o n y o v e r h a ng s t h a t h i nde r wo r k wi t h i n t he
c a na l . T wo i mpo r t a nt po i nt s mus t b e r e me mb e r e d.
( I ) T h e c a na l r uns a nt e r i o r t o po s t e r i o r a s i t b e c o me s
mo r e me di a l ; t h us mo r e b o ne wil l be r e mo v e d ne a r
t he po s t e r i o r f os s a dur a , a nd o nl y mi ni ma l b o n e
r e mo va l wi l l be ne e de d a t t he s upe r i o r c a na l a mpul l a
l a ndma r k ( wh i c h wa s l eft b e h i nd) . T h e c o ur s e i t wi l l
r un a ppr o x i ma t e s a l i ne f r om t he s e c o nd ge nu of t he
facial ne r v e t o t he s i no dur a l a ngl e . ( 2) T h e c a na l wil l
be ve r y e x pa nde d o wi ng t o t h e pr e s e nc e o f t h e t umo r
( Fi g. 1 9 - 4 C) .
Bo ny t r o ugh s a r e c r e a t e d a r o und t h e s upe r i o r a nd
i nf e r i or b o r de r s o f t h e i nt e r na l a udi t o r y c a na l ; t h e y
a r e d e e p e n e d b e t we e n t h e t e g me n a nd t he c a na l a nd
b e t we e n t h e j ugul a r bul b a nd t h e c a na l , r e s pe c t i ve l y ,
unt i l t h e po s t e r i o r h a l f o f t h e c a na l h a s b e e n e x po s e d
a nd t he b o ne h a s b e e n t h i nne d t o e ggs h e l l t h i c kne s s .
S upe r i o r l y , c a ut i o n i s n e e d e d s i nc e o c c a s i o na l l y t he
facial ne r v e c r o s s e s t h e s upe r i o r a s pe c t o f t h e t umo r
a nd ma y b e i nj ur e d wi t h t h e d i a mo n d bur . T h e bur
bit s h o ul d a l wa y s r ot a t e t o wa r d t he t e gme n, t o pr e-
v e nt " j u mp i n g " i nt o t he c a na l i f i t c a t c h e s on a b o ny
l e dge ; t h i s i nv o l v e s c l o c kwi s e r ot a t i on i n a left e a r
a nd c o unt e r c l o c kwi s e r ot a t i on i n a r i ght e a r . In de -
v e l o pi ng t h e " t r o ug h " i nt e r i or l y, t he c o c h l e a r a que -
duc t i s f o und b e t we e n t h e j ugul a r bul b a nd t h e c a na l .
It us ua l l y a ppe a r s as a wh i t e s po t , a nd i ns e r t i ng a
pi c k i nt o i t of t e n pr o duc e s a c e r e b r o s pi na l f l ui d l eak.
Th i s i s a n i mpo r t a nt l a ndma r k, s i nc e t he ni nt h ne r v e
i s j us t a nt e r o i nf e r i o r a nd me di a l t o i t as i t e xi t s t h e
334 T u mo r s o f t h e Mi ddl e a nd I nne r Ea r
skul l t o pr o c e e d a c r o s s t h e me di a l s upe r i o r a s pe c t of
t he j ugul a r bul b. I n o r de r t o pr o t e c t t h i s ne r ve ,
di s s e c t i o n s h o ul d not pr o c e e d a nt e r i o r l y t o t he c o c h -
l ear a que duc t . Fo c us i ng o n t h e s upe r i o r c a na l a m-
pul l a, t h e s upe r i o r ve s t i bul a r ne r v e c a n be i dent i f i ed
t h r o ugh t h e b o ne by c a r e f ul di s s e c t i o n wi t h a di a-
mo nd bur . Wi t h c o nt i nuo us o npi o us i r r i ga t i on t o
pr e ve nt h e a t t r a ns f e r f r om t he bur , t h e facial ne r ve
c a n be bl ue - l i ne d a nd i de nt i f i e d a s i t e nt e r s t he
l a b y r i nt h i ne por t i on o f t h e f a l l opi a n c a na l , me di a l
a nd s l i gh t l y s upe r i o r t o wh e r e t he s upe r i o r ve s t i bul a r
ne r v e e nds . (It ma y be f o l l o we d f or a s h o r t di s t a nc e
i n its l a by r i nt h i ne c o ur s e for po s i t i ve i de nt i f i c a t i on. )
I nf er i or t o t h e s upe r i o r ve s t i bul a r ne r v e i s t he t r a ns -
ve r s e c r e s t , wh i c h di vi de s t h e l a t e r a l mo s t e nd o f t he
i nt e r na l a udi t o r y c a na l i nt o s upe r i o r a nd i nf er i or
c o mp a r t me n t s ( Fi g. 1 9 - 5 / 4 ) . I f t he b o ne r e ma i ni ng
o ve r t he c a na l h a s b e e n t h i nne d pr o pe r l y , us ua l l y i t
can be c r a c ke d wi t h pr e s s ur e f r om a bl unt i ns t r ume nt
a nd r e mo v e d i n o n e pi e c e , o r dr i l l e d c a r e f ul l y wi t h
a di a mo nd bur . It i s i mpo r t a nt t o c o mpl e t e l y r e mo v e
t h e b o n e f r om t h e po s t e r i o r h a l f o f t h e c a na l . Th e
t umo r i t s el f i s no w e x po s e d a nd b o ne o v e r l y i ng t he
po s t e r i o r f os s a dur a h a s b e e n r e mo v e d c o mpl e t e l y ,
fr om t he s i gmo i d s i nus t o t he p o ms a c us t i c us ( l at er al
t o me di a l ) a nd fr om t he t e g me n t o t h e j ugul a r bul b
( s upe r i o r t o i nf e r i or ) .
A dur a l f l ap i nc i s i on i s b e g un po s t e r o s upe r i o r l y
t o t he j ugul a r bul b, a nd c a r r i e d a c r o s s t h e po r us
a c us t i c us a nd t h e n l at er al l y up t he po s t e r i o r f ossa
dur a par al l el t o t he s upe r i o r pe t r os a l s i nus . Its infe-
rior l i mb ni a v be c a r r i e d l at cr al l v a l o ng ( h e s i gmo i d
s i nus . I he Hap i s pul l e d b a c kwa r d a nd t h e pos t e r i or
s ur f a c e of t h e t umo r i s \ i s ua l i / e d ( Fi g. I S* ^ / * ) . I he
i nc i s i o ns mus t h e ma de c a ut i o us l v s o t hat a nv un-
de r l yi ng v e s s e l s a nd ne r v e s a r e not i nj ur e d. Ka r e l v.
t he tacial ne r v e t r a ve r s e s t he s upvr i or a s pe c t ol t he
t umo r ( UMUI I V i t i s on t h e . i nt e r i or s ur l i i i e ) ; t he
pe t r os a l vei n i s l o und a l o ng l l i r po s t e r i o r a s pe c t ,
dr a i ni ng i nt o t he s upe r i o r pe t r os a l ve i n. At t he tu-
mo r ' s i nf e r i or a s pe c t , t he c i s t e ma ma gna us ua l l v c a n
be vi s ua l i ze d a nd ge nt l y pr o b e d t o o bt a i n a pr o f us e
c e r e b r o s pi na l f l ui d l e a k. Thi s wi l l r e l e a s e pr e s s ur e
a nd a l l o w t h e c e r e b e l l um t o r el ax. The pl a ne b e t we e n
t he po s t e r i o r a s pe c t o f t h e t umo r a nd t he a r a c h no i d
i s de v e l o pe d, a nd t h e dur a l fl ap i s l aid i n t he pl a ne
t o pr o t e c t t h e c e r e b e l l um (if po s s i bl e , i nc l ude t he
pe t r os a l ve i n unde r t he f l a p) . L o ng Co t t o no i d s t r i ps
ma y a l s o be l aid t o pr ot e c t t he c e r e b e l l um a nd h e l p
i n de v e l o pi ng t h e pl a ne . De v e l o pi ng t he pr o pe r pl a ne
wil l pr o duc e l e s s b l e e di ng.
At t hi s poi nt t he l at er al e nd of t he t umo r i s
mo b i l i ze d f r om t h e facial ne r v e . By r ot a t i ng t he t abl e
a wa y t he a r e a i s b r o ugh t i nt o vi e w. T h e s upe r i o r
ve s t i bul a r a nd facial ne r v e s a r e i de nt i f i e d. Us i ng a
bl unt r i gh t - a ngl e d h o o k, t h e r i dge o f b o ne ( Bi l l ' s b
:
r )
t ha t s e pa r a t e s t h e s upe r i o r ve s t i bul a r a n d fac a l
ne r v e s i s i de nt i f i e d a nd pa l pa t e d by f i ndi ng t he e* d
of t he s upe r i o r ve s t i bul a r ne r v e a nd f o l l o wi ng Hie
b o ne b a c kwa r d unt i l i t e nds ( wh i c h i s wh e r e t he
facial c a na l b e gi ns ) . Th i s is c r uc i a l to pr e s e r v i ng H e
facial ne r v e , s i nc e e v e r y t h i ng l at er al t o t hi s r i dge i s
ve s t i bul a r ne r v e a nd ma y b e a v ul s e d s a f e l y ( Fi g. 1 9 -
5 C) . As t h e a v ul s e d ne r v e i s pul l e d ba c k, t h e facial
ne r v e i s b r o ugh t i nt o full v i e w b e h i nd. It i s be s t not
t o pr o b e i nt o t h e f aci al c a na l i n o r de r t o pr e v e nt
t r a uma t o a nd s we l l i ng of t h e facial ne r v e . T h e first
f e w mi l l i me t e r s of t h e f aci al ne r v e a r e c l e a ne d o
i dent i f y i t pos i t i ve l y. Ar a c h no i d t hat e nv e l o ps \h?.
ne r v e on its s upe r i o r a nd i nf e r i or e dg e s i s s e pa r a t e d
wi t h t h e h o o k ( Fi g. 1 9 - 5 D ) . Of t e n t h i s i s diffice. j ,
s i nc e t h e ne r v e ma y t hi n c o ns i de r a b l y a nd ma k e t he
ne r v e e dge s h a r d t o di s t i ngui s h . I nf e r i or t o t h e s i -
pe r i or ve s t i bul a r ne r v e i s t h e t r a ns v e r s e c r e s t ; s
me nt i o ne d pr e v i o us l y , i t s e pa r a t e s t h e s upe r i o r a
-
i
i nf e r i or c o mpa r t me nt s of t h e i nt e r na l a udi t o r y c a nr .
T h e i nf e r i or c o mp a r t me n t i s c l e a ne d o f t umo r wi l l
t he h o o k. A t o ngue of t umo r of t e n e x t e nds u/>
b e t we e n t he t r a ns v e r s e c r e s t a nd i nf e r i or c o mp a r -
me nt a nd mus t b e s we pt c l e a n ( Fi g. 19- 6/ A) . T h
i nf e r i or ve s t i bul a r ne r v e i s a v ul s e d, a nd us ua l l y t he
c o c h l e a r ne r v e a s we l l . T h e a nt e r o i nf e r i o r c e r e be l l a r
a r t e r y us ua l l y l i es a l o ng t he i nf e r i or b o r de r of t he
t umo r , a nt e r i o r t o t h e c o c h l e a r ne r v e . Th i s i mpo r t e d*
ve s s e l mus t a l wa y s be wa t c h e d for a nd pr o t e c t ?- !
f r om i nj ur v. T h e t umo r i s pul l e d t o wa r d t h e s ur ge o n
dur i ng t hi s l at er al mo bi l i za t i o n.
I h e pr o c e dur e t r o m t h i s poi nt d e p e n d s o n t i e
s i / e ot t h e t umo r . Di s s e c t i o n ma v pr o c e e d as obo" i ;
h o we v e r , f or a l a r ge r t umo r de b ul ki ng wil l be
qui r e d, t o pr e ve nt t r a c t i on f r om be i ng pl a c e d on t . e
facial ne r v e as [ l i e t umo r i s r ol l ed a wa v I r om it. i n
de b ul ki ng, t h e t umo r i s o p e n e d o v e r its po s t e n *r
s ur f a c e a nd t he c o nl v nt s , ue r e mo v e d " i nt r a c a ps a -
l a r l v, " a l l o wi ng i t t o c o l l a ps e i nwa r d. Th i s c a n v
a c c o mpl i s h e d wi t h an Ur b a n di s s e c t o r , l a s e r ( Fi g. 1 f
b/ *) , Ca vi t r o n, or c up f o r c e ps . Ca r e i s t a ke n t o r e ma i n
i ns i de t he c a ps ul e i n o r de r t o pr e ve nt i nj ur y t o ne r v ' 5
or v e s s e l s t hat ma y t r a ve r s e t he t umo r s ur f a c e . W: h
a de qua t e de b ul ki ng t h e t umo r wi l l c o l l a ps e i nwa r I ,
a l l o wi ng f ur t h e r mo bi l i za t i o n f r om t he f aci al ne r e
a nt e r i o r l y ( Fi g. 1 9 - 6 C) a nd t h e b r a i ns t e m po s t e r i o r y
( Fi g. 1 9 - 6 D ) . Bi po l a r c a ut e r y ma y be us e d t o c ont ; >1
b l e e di ng wi t h i n t he t umo r , wh i c h o c c a s i o na l l y
:
s
a b unda nt . Wi t h l a r ge t umo r s , t h e ni nt h ne r v e m- v
t r a ve r s e t he c a ps ul e i nt e r i or l y. Us ua l l v t h e a nt e r o i . -
( er i or c e r e be l l a r a r t e r y h a s b e e n pus h e d i nf e r i or l y '~y
t umo r gr o wt h . S upe r i o r l y t h e fifth ne r ve ma y er e? s
t he c a ps ul e i n l a r ge t umo r s ; o c c a s i o na l l y , t h e s e v e n; i
ne r ve ma y t r a ve r s e t h e s upe r i o r e dg e o f t he t umo : .
T u mo r s o f t he Mi ddl e a nd I nne r Ea r
FIGURE 19-5.
336 T u mo r s o f t h e Mi ddl e a nd I nne r Ea r
FIGURE 19-6.
Tumo r s o f t h e Mi ddl e a nd I nne r Ea r 337
Dur i ng mo bi l i za t i o n a nd t umo r r e mo v a l , t h e s e s t r uc -
t ur e s mus t be wa t c h e d for a nd pr o t e c t e d.
Af t e r a de qua t e de b ul kj ng, t h e pl a ne for t h e facial
ne r v e i s f ur t h e r de v e l o pe d a nd t h e t umo r c o nt i nue s
t o be r ol l ed t o wa r d t h e s ur ge o n. I t i s i mpo r t a nt
( a l t h o ugh di f f i cul t ) t o a vo i d pus h i ng t h e t umo r ma s s
i nwa r d, wh i c h ma y s t r e t c h t h e t h i nne d ne r ve . I t i s
be s t t o f ol l ow t h e facial ne r v e t o t h e b r a i ns t e m,
s e pa r a t i ng a nd r e mo v i ng t h e t umo r a s t h e pl a ne
c o nt i nue s t o be de v e l o pe d. At t h e po r us a c us t i c us
t h e facial ne r ve us ua l l y t h i ns c o ns i de r a b l y , ma ki ng
t h e di s s e c t i o n di f f i cul t . Of t e n i t i s ne c e s s a r y t o r e t ur n
t o t h e po s t e r i o r , i nf e r i or , a nd s upe r i o r b o r de r s of t h e
t umo r t o de v e l o p t h i s pl a ne (if ne e de d for ma ne u-
ve r i ng) . Al wa y s t r y t o a vo i d pus h i ng t h e t umo r
a nt e r i o r l y . On c e t h e f aci al ne r ve h a s b e e n f r eed f r om
t he t umo r , t h e bul k of t h e t umo r i s r e mo v e d t o
e n h a n c e vi s ua l i za t i on ( Fi g. 1 9 - 6 / : ) . T h e pl a ne be -
t we e n t h e r e ma i ni ng t umo r a nd t h e b r a i ns t e m i s
de v e l o pe d a nd c a r e i s e xe r c i s e d s upe r i o r l y for t h e
fifth ne r v e a nd i nf e r i or l v for t h e a nt e r o i nf e r i o r c e r e -
be l l a r a r t e r y ( Fi g. 1 9 - 6 ) . Ve s s e l s t ha t t r a ve r s e t h e
t umo r s ur f a c e a r e di s s e c t e d a wa y , i f po s s i bl e ; i f not ,
t h e y a r e c a r e f ul l y c l i ppe d or c a ut e r i ze d. Wi t h car ef ul
di s s e c t i o n, t ot al r e mo v a l o f t h e t umo r c a n be a c c o m-
pl i s h e d i n a l mo s t all c a s e s .
Be f o r e c l o s ur e , s uf f i c i e nt t i me mus t be t a ke n t o
e ns ur e t hat a de qua t e h e mo s t a s i s i s o b t a i ne d wi t h i n
t h e c e r e b e l l o po nt i ne a ngl e . Fat i s t a ke n f r om t h e
a b d o me n a nd pl a c e d i n l o ng s t r i ps j us t i ns i de t h e
dur a l o pe ni ng; t hi s h a s b e e n f o und t o pr o vi de a go o d
s eal a ga i ns t po s t o pe r a t i v e c e r e b r o s pi na l fl uid l eak-
a ge . T h e l o ng t ai l s o f t h e s t r i ps a r e t h e n f ol ded i nt o
t he ma s t o i d c a vi t v a nd a nt r um, a nd t h e po s t a ur i c ul a r
i nc i s i on i s c l o s e d.
Intraoperative Complications or
Problems
1. S i g mo i d a nd s upe r i o r pe t r os a l s i nus bl e e di ng.
2. J ugul a r bul b bl e e di ng.
3. Fa c i a l ne r v e a vul s i o n.
4. Vi t a l s i gn c h a ng e s .
Sinus Bleeding. Bl e e di ng a r i s i ng f r om i nj ur y to t h e
s i nus dur i ng b o ne r e mo v a l ma y be pr o f us e a t t i me s .
Al t h o ugh a l a r mi ng, wi t h pr o pe r ma n a g e me n t i t ma y
b e c o nt r o l l e d wi t h o ut s e r i o us c o n s e q u e n c e s . S i gmo i d
b l e e di ng a r i s i ng f r om e mi s s a r y ve i ns us ua l l y c a n be
c o nt r o l l e d by full e x po s ur e of t h e vei n a nd bi po l a r
c a ut e r y ; pa c ki ng wi t h b o n e wa x o r S ur gi c e l i s a no t h e r
o pt i o n. Fo r t e a r s wi t h i n t h e s i nus i t s el f , pa c ki ng wi t h
S ur gi c e l wi l l c o nt r o l t h e i mme di a t e pr o b l e m o f bl ood
l os s ; h o we v e r , i f b o ne r e mo v a l h a s b e e n c o mpl e t e d
t h e r e a r e no b o ny l e dge s a ga i ns t wh i c h t o we d g e t h e
pa c ki ng. La r ge pa c ks h i nde r di s s e c t i o n mo r e me di -
al l y; i n a ddi t i o n, t h e pa c ks ma y be c a ugh t i n t h e
dr il l , c r e a t i ng a wh i ppi ng a c t i o n wi t h t h e S ur gi c e l .
On e s o l ut i o n t o t hi s i s t o c o v e r t h e pa c ki ng wi t h
b o ne wa x dr a pe d o v e r Bi l l ' s i s l a nd; a l o ng s t r i p of
Co t t o no i d i s t h e n dr a pe d o v e r t h e a r e a a nd t h e e nt i r e
c o mpl e x i s r e t r a c t e d wi t h t h e s uc t i o n i r r i ga t or o r wi t h
a ma l l e a b l e r e t r a c t or h o o ke d t o t h e c e r e be l l a r r e t r a c -
t or s . Aga i n, b l e e di ng us ua l l y c a n be c o nt r o l l e d; t h e
o bj e c t i ve i s t o c o nt i nue di s s e c t i o n f a r t h e r me di a l l y
wi t h o ut h i ndr a nc e .
Jugular Bulb Bleeding. I na dv e r t e nt i nj ur y to t h e
j ugul a r bul b i s s i gna l e d by pr o f us e bl e e di ng. P a c ki ng
i mme di a t e l y wi l l c o nt r o l t h e b l e e di ng. Ca ut i o n mus t
be e x e r c i s e d s i nc e t h e ni nt h , t e nt h , a nd e l e v e nt h
ne r v e s a r e i n t hi s a r e a a nd ma y be i nj ur e d by i nj u-
di c i o us pa c ki ng. Fo r s ma l l t e a r s i n t h e j ugul a r bul b,
pa c ki ng ma y c o nt r o l t h e b l e e di ng a nd a l l o w t h e
pr o c e dur e t o c o nt i nue . On l y l a r ge pi e c e s o f pa c ki ng
ma t e r i a l a r e t o be us e d h e r e , i n o r de r t o pr e ve nt
di s pl a c e me nt o f ma t e r i a l i nt o t h e l ume n o f t h e ve i n
a nd a r e s ul t i ng pul mo na r y e mb o l u s ( t h i s i s a l s o a
c o nc e r n wi t h t ear s i n t h e s i gmo i d) . Fo r l a r ge t e a r s , i t
i s of t e n ne c e s s a r y a nd s a f e r t o tie t h e ve i n of f i n t h e
ne c k by e x t e ndi ng t h e po s t a ur i c ul a r i nc i s i o n i nt er i -
or l y ( f or al l ne ur o l o gi c pr o c e dur e s t h e uppe r ne c k i s
i nc l ude d i n t h e dr a pi ng) . T h e j ugul a r bul b i s t h e n
pa c ke d i nt r a l umi na l l y t o pr e v e nt ba c k- bl e e di ng,
Facial Nerw Avulsion. If t h e f aci al ne r v e is l os t or
a vul s e d dur i ng t umo r r e mo v a l , a de c i s i o n mus t be
ma de wh e t h e r t o a t t e mpt i mme di a t e o r de l a y e d re-
h a bi l i t a t i on. Be c a us e t h e b e s t a nd mo s t c o ns i s t e nt
r e s ul t s a r e o b t a i ne d f r om i mme di a t e r e h a bi l i t a t i on, i t
s h o ul d be a t t e mpt e d i f po s s i bl e . I f t h e b r a i ns t e m s i de
of t h e a v ul s e d ne r ve i s f o und a nd i s l o ng e no ug h ,
t h e i nf r a t e mpo r a l por t i on of t h e facial ne r v e ma y be
mo bi l i ze d i n its e nt i r e t y f r om i t s c a na l . Wi t h t hi s
ma ne uv e r , a n a ddi t i ona l 1-cm l e ngt h of ne r v e i s
o bt a i ne d ( b y pa s s i ng t h e l a by r i nt h i ne a nd t e mpo r a l
c o ur s e o f t h e ne r v e ) a nd a n e nd- t o - e nd a na s t o mo s i s
ma y be a t t e mpt e d. If po s s i bl e , a s ut ur e i s pl a c e d t o
h ol d t h e a v ul s e d e nds t o ge t h e r ( c o l l a ge n [ Avi t e ne j
h a s b e e n pl a c e d a r o und t h e t wo e nds t o h ol d t h e m
i n a ppo s i t i o n) . If t hi s i s no t f e a s i bl e , a h y po gl o s s a l -
facial ne r v e a na s t o mo s i s i s pe r f o r me d l at er .
Vital Sign Changes. Vi t al s i gns a r e c o ns t a nt l y mo n-
i t or e d t h r o ugh o ut t umo r r e mo v a l s ur ge r y . Co nt i nu-
o us c a r di a c mo ni t o r i ng i s do ne , a s we l l a s mo ni t o r i ng
of bl o o d pr e s s ur e wi t h ar t er i al l i ne s . Wi t h a ny r ise
or c h a ng e i n b l o o d pr e s s ur e or pul s e r e gul a r i t y, t h e
s ur ge o n i s not i f i e d, t r a c t i on i s s t o ppe d, a nd l a r ge
Co t t o no i d pa c ki ng i s r e mo v e d i n o r de r t o e l i mi na t e
pr e s s ur e o n v e s s e l s . Us ua l l y r e s po ns e s r e t ur n t o
no r ma l i n a f e w mi nut e s a nd s ur ge r y c o nt i nue s , i t
t h e y r e c ur , a de c i s i o n i s ma d e wh e t h e r t o c o nt i nue
s ur ge r y but o nl y pe r f o r m a s ubt o t a l r e mo v a l ; i f t umo r
i s left b e h i nd, i t ma y be r e mo v e d e l e c t i ve l y i n a b o ut
six mo nt h s . By t hat t i me t he b r a i ns t e m c i r c ul a t i on
h a s us ua l l y i mpr o v e d f r om t umo r de b ul ki ng a nd
r e l e a s e o f pr e s s ur e , a nd t ot al t umo r r e mo v a l c a n b e
pe r f o r me d s a f e l y . Co ns t a nt mo ni t o r i ng a nd r e pl a c e -
me n t o f b l o o d l o s s i s i mpo r t a nt t o pr e v e nt e a r l v s i gns
o f s h o c k ( i nc r e a s e d pul s e , de c r e a s e d BP ) f r o m of f s et -
t i ng t h e e f f e c t o f v e s s e l t r a c t i on o r s p a s m ( de c r e a s e d
pul s e , i nc r e a s e d BP ) .
Pertinent Histopathology
F I G UR E 1 9 - 7
Th i s h o r i zo nt a l s e c t i o n o f a t e mpo r a l b o n e s h o w?
t he pr e s e nc e o f a n a c o us t i c n e u r o ma .
CHAPTER 20
Plastic Surgery
of the Pinna
T h e pi nna , or a ur i c l e , i s t he pr o j e c t i ng par t of t he
ear t ha t l i es o ut s i de t h e h e a d; its ba s i c a n a t o my i s
s h o wn i n Fi gur e 2 0 - 1 . I t c o ns i s t s o f t wo t y pe s o f
t i s s ue : e l a s t i c ( y e l l o w) c a r t i l a ge a nd, i n t h e e a r l obe ,
f i br oa r e ol a r t i s s ue . I t i s c o nne c t e d t o t h e h e a d a nd
s c a l p by t he s upe r i o r , a nt e r i o r , a nd po s t e r i o r aur i -
c ul a r mus c l e s . Bl o o d i s s uppl i e d t o t he pi nna by
b r a nc h e s o f t h e s upe r f i c i a l t e mpo r a l a nd po s t e r i o r
a ur i c ul a r a r t e r i e s , a nd i t i s i nne r v a t e d by b r a nc h e s of
t he gr e a t e r a ur i c ul a r a nd a ur i c ul o t e mpo r a l ne r ve s ,
t he ma s t o i d b r a nc h o f t h e l e s s e r oc c i pi t a l ne r ve , a nd
a s ma l l b r a nc h of t h e v a gus ne r ve i n t h e c o nc h a
b o wl . Th i s c h a pt e r de s c r i b e s s e ve r a l s ur gi c a l pr o c e -
dur e s f or r e pa i r a nd r e c o ns t r uc t i o n o f t h e pi nna .
Treatment of the Cleft Ear Lobe
P a t i e nt s a r e of t e n s e e n i n t he c l i ni c wi t h cl ef t e a r
l o be s s e c o nda r y t o t r a uma f r om pi e r c i ng t he e a r for
e a r r i ngs . T h e y mo s t of t e n pr e s e nt wi t h a h e a l e d cl ef t ,
but o c c a s i o na l l y wi t h a " f r e s h " or i nc o mpl e t e cl ef t ;
ve r y r a r e l y a c o nge ni t a l cl eft i s s e e n. Re ga r dl e s s of
the pr e s e nt a t i o n, t h e t r e a t me nt i s t he s a me
Aim
To c o r r e c t a cl eft e a r l o be de f e c t
Highlights
1. Ma k e a Z- pl a s t y or V- pl a s t y at t he f r ee ma r gi n
t o pr e v e nt po s t o pe r a t i v e no t c h i ng.
2. Do no t us e a po s t - t y pe e a r r i ng t o ma i nt a i n t he
e a r r i ng h o l e af t er t he r e pa i r ; e v e n a l i gh t we i gh t
e a r r i ng wi l l e nl a r ge t he h o l e po s t o pe r a t i v e l y .
Pitfalls
1. Fa i l i ng to pe r f o r m a Z- pl a s t y of t e n r e s ul t s in a
no t c h at t h e f r ee ma r gi n of t h e l o be a nd a de pr e s s e d
s car .
2. I f t h e pa t i e nt we a r s a n e a r r i ng t oo s o o n af t er
t he r e pa i r , a n e nl a r ge d e a r r i ng h o l e wil l r e s ul t
Instruments
No . 11 a nd No . 15 s c a l pe l b l a de s a nd h a ndl e s .
T wo s ki n h o o k s , e i t h e r s i ngl e o r do ub l e h o o k t ype .
0. 5 - mm o ph t h a l mi c f o r c e ps .
Fi ne S t o r z " s t i t c h " s c i s s o r s .
S ut ur e s : 5- 0 Vi c r yl on a c ut t i ng ne e dl e , 6- 0 c h r o mi c
or 6- 0 ny l o n on a s ma l l c ut t i ng ne e dl e , 0 pr o l e ne
or ny l o n
340 Pl a s t i c S ur ge r y of t h e P i nna
Ant. auricular muscle
Pl as t i c S ur ge r y o f t h e P i nna 341
Procedure
Li do c a i ne 1 t o 2% wi t h 1: 100, 000 e pi ne ph r i ne i s
us e d. Fi r s t t h e e dg e s of t he cl eft a r e e xc i s e d- I f t h e
cl eft i s no t qui t e c o mpl e t e , t h e s ma l l br i dge o f s ki n
a l s o i s e x c i s e d. A Z- pl a s t y i s f a s h i o ne d a nt e r i or l y
( Fi g. 20-2-A-C). O n e c a n a l s o be ma d e pos t e r i or l y,
but t hi s i s not ne c e s s a r y . A Z- pl a s t y s h o ul d a l s o be
ma de a t t h e fr ee ma r gi n of t h e l o be t o pr e v e nt a
s ma l l no t c h f r om f o r mi ng dur i ng t h e h e a l i ng pr o c e s s
Al t e r na t i ve l y , t he f r ee ma r gi n c a n be c l o s e d i n a " V "
t o ngue - a nd- gr o o v e f a s h i o n. I f t he pa t i e nt stil l wi s h e s
to h a v e a pi e r c e d e a r , a l e ngt h of 0 pr o l e ne s ut ur e is
f o r me d i nt o a 1-in l o o p pa s s i ng t h r o ugh t h e f o r me r
e a r r i ng s i t e . S o me pa t i e nt s , not wi s h i ng t o h a v e t h e
l oop o f s ut ur e i n t h e i r l o be for s e ve r a l we e ks , ma y
de c i de s i mpl y t o h a v e t h e e a r r e pi e r c e d af t er t h e
r e pa i r h a s h e a l e d. T h e f i br oa r e ol a r t i s s ue i s c l o s e d
wi t h i nt e r r upt e d 5- 0 Vi c r yl a nd t h e s ki n i s c l o s e d
wi t h i nt e r r upt e d 6- 0 ny l o n o r 6- 0 c h r o mi c s ut ur e s .
Ba c i t r a c i n o i nt me nt i s a ppl i e d t o t h e i nc i s i o n f or a
f ew da y s . 6- 0 ny l o n s ut ur e s a r e r e mo v e d a t f our t o
five da y s . I f 6- 0 c h r o mi c s ut ur e s a r e us e d, t h e pa t i e nt
c a n be s e e n a t s e v e n t o 10 da y s , a t wh i c h t i me t he
r e ma i ni ng wi s ps o f s ut ur e c a n be ge nt l y wi pe d off.
An e a r r i ng ma y b e wo r n af t er f our we e k s .
Treatment of Keloids
Ke l o i ds a r e a c o mmo n pr o b l e m of t h e e a r l o b e ,
e s pe c i a l l y i n bl a c ks . T h e y us ua l l y i nv o l v e t he me di a l
a s pe c t o f t he l o be , a nd mo s t of t en a r e t h e r e s ul t o f
de e p de r ma l i nj ur y t o t h e l o be o f t h e e a r wh e n t h e
e a r s a r e pi e r c e d for e a r r i ngs . La r ge l e s i o ns c a n be
pai nf ul wh e n h o l di ng a t e l e ph o ne r e c e i ve r a ga i ns t
t h e e a r o r wh e n s l e e pi ng. An y ke l o i d l a r ge e no ug h
t o c a us e a c o s me t i c or f unc t i ona l de f e c t s h o ul d be
e xc i s e d.
Aim
To e x c i s e a nd pr e v e nt t h e r e c ur r e nc e o f t h e e a r
l obe ke l o i d.
Highlights
1. T h e ke y t o t r e a t me nt i s t o pr e v e nt r e c ur r e nc e
af t er e xc i s i o n. Th i s i s a c c o mpl i s h e d wi t h i nt r a l e s i ona l
s t e r oi d i nj e c t i o ns a nd t h e us e o f pr e s s ur e e a r r i ngs .
2. S t a y a s c l o s e a s po s s i b l e t o t he s t a l k of t h e
ke l oi d dur i ng e xc i s i o n, i n o r de r t o pr e s e r v e a s mu c h
no r ma l s ki n o f t he e a r l o be a s po s s i bl e .
Pitfalls
1. Re pi e r c i ng of t he l o be af t er s uc c e s s f ul t r e a t me nt
of a ke l oi d i s no t r e c o mme n d e d .
2. Fa i l i ng t o pr e v e nt a r e c ur r e nc e i s t h e mo s t
c o mmo n pr o b l e m af t er e xc i s i o n of a ke l o i d. Cl o s e
f o l l o w- up a nd t h e us e o f i nt r a l e s i o na l s t e r o i ds ar e
t he be s t me t h o d s of pr e v e nt i ng a r e c ur r e nc e .
3. T h e pa t i e nt wi t h l a r ge ke l o i ds mus t be a dv i s e d
t hat t h e e a r l o be ma y be l e s s f l e s h y af t er e xc i s i o n o f
t he ke l o i d; t h a t o wi n g t o t h e ma s s o f t h e ke l o i d, l ittl e
f i br of at t y t i s s ue i s a va i l a bl e f or a d v a n c e me n t i nt o t h e
wo und f or c l o s ur e ; t hat t h e l o be ma y be s ma l l e r af t er
e xc i s i on o f t h e ke l oi d, o wi ng t o t he e xc i s i o n o f s ki n
o n b o t h s ur f a c e s o f t h e l o be ; a nd t ha t t h e l o be ma y
be r ot a t e d s l i gh t l y a nt e r i o r l y af t er t h e e xc i s i o n of a
l at er al ke l oi d a nd s l i gh t l y po s t e r i o r l y af t er t h e exci -
s i on of a me di a l ke l o i d.
Instruments
No . 1 a nd No . 15 s c a l pe l b l a de s a nd h a ndl e s .
0. 5 - mm o ph t h a l mi c f o r c e ps .
A f i ne ne e dl e h o l de r .
St o r z "s t i t c h " s c i s s o r s .
Ski n h o o ks , e i t h e r s i ngl e o r do ub l e .
S ut ur e s : 5- 0 c h r o mi c or Vi c r y l , a nd 6- 0 c h r o mi c or 6-
0 ny l o n on a s ma l l c ut t i ng ne e dl e .
Procedure
T h e t r e a t me nt o f ke l o i ds i nvo l ve s t h r e e t r e a t me nt
mo da l i t i e s , s t e r o i d t h e r a py , pr e s s ur e t h e r a py , a nd
e xc i s i o n. T h e s e mo da l i t i e s a r e of t e n us e d a t di f f er ent
t i me s i n t h e t r e a t me nt o f t h e s a me ke l oi d.
Sma l l ke l o i ds c a n be t r e a t e d wi t h i nj e c t i o ns o f 40
mg pe r ml o f t r i a mc i no l o ne a c e t o ni de e v e r y f our t o
six we e ks . T h e s t e r oi d c a n e i t h e r be de l i ve r e d wi t h a
De r ma j e t a ppa r a t us o r i nj e c t e d i nt o t he de r mi s wi t h
a 2 5 - or 2 7 - ga uge ne e dl e . A De r ma j e t ne e dl e l e s s
i nj e c t or di s pe ns e s 0. 1 ml of t h e s t e r oi d s o l ut i o n i n a
f i ne dr o pl e t f or m uni f o r ml y i nt o t h e t i s s ue s ; t h i s
a vo i ds t h e b o l us i nj e c t i on o f s t e r o i ds t hat c a n r e s ul t
f r om di r e c t ne e dl e i nj e c t i on i nt o de ns e s c a r t i s s ue .
Pl a s t i c S ur g e r y o f t h e P i nna 343
Ov e r z e a l o u s i nj e c t i o n c a n c a us e s ki n a t r o ph y , t e l a n-
gi e c t a s i s , a nd h y po pi g me nt a t i o n. I t ma y t a ke s i x t o
12 mo n t h s t o r e s o l v e t h e ke l o i d.
It i s a l s o po s s i b l e t o t r eat s ma l l ke l o i ds wi t h pr e s -
s ur e t h e r a py . A pr e s s ur e - t y pe c l a s p e a r r i ng ( P a dge t t
Co , Ka n s a s Ci t y , MO ) ma y s uppl y e n o u g h pr e s s ur e
t o b l a nc h t h e c a pi l l a r i e s s uppl y i ng t h e f i br o us t i s s ue
a nd c a us e a r e gr e s s i o n of t h e l e s i o n. I t mus t be wo r n
c o nt i nuo us l y f or s e ve r a l mo n t h s . Wh e n t h e e a r r i ng
i s t a ke n o f f t h e ke l oi d c a n r e c ur ; t h e r e f o r e , i t i s
pr o b a b l y b e s t t o c o mb i n e us e o f t h e pr e s s ur e e a r r i ng
wi t h mo n t h l y s t e r o i d i nj e c t i o ns .
For ke l o i ds t hat a r e t oo l a r ge for pr e s s ur e t h e r a py
or t hat do no t r e s po nd t o s t e r o i ds , e x c i s i o n i s i ndi -
c a t e d. T h e e nt i r e ke l o i d s h o ul d b e e x c i s e d. De l i c a t e
h a ndl i ng i s ne c e s s a r y t o pr e v e nt t r a uma t o t h e s ur -
r o undi ng t i s s ue s . I f t h e ke l o i d i s e s pe c i a l l y l a r ge , i t
i s i mpo r t a nt t o f r ee up s ur r o undi ng f i br of a t t y t i s s ue
t o fill i n t h e s of t t i s s ue de f e c t . A W- pl a s t y or Z- pl a s t y
i s us e d t o c a mo uf l a g e t h e r e pa i r . S o me t i me s a s ma l l
r o t a t i o na l f l ap mus t be us e d f or c l o s ur e . S t e r o i ds c a n
be i nj e c t e d di r e c t l y i nt o t h e s ur gi c a l s i t e a t t h e e nd
of t h e pr o c e dur e . 5- 0 c h r o mi c or Vi c r yl i s us e d for
de e p s ut ur e s a nd 6- 0 c h r o mi c o r ny l o n i s us e d o n
t he s ki n.
Ba c i t r a c i n i s a ppl i e d for a f e w da y s . Ny l o n s ut ur e s
c a n be r e mo v e d af t er f our t o f i ve da y s . Wh e n e xc i s i o n
a l o ne i s us e d t h e r e c ur r e nc e r at e i s o v e r 50vl ; t h e r e -
f or e, t h e s ur gi c a l s i t e s h o ul d be i nj e c t e d wi t h s t e r o i ds
e v e r y mo n t h f or a ppr o x i ma t e l y six mo n t h s o r unt i l
t he s c a r i s ma t ur e . To s t a bi l i ze t he e a r ki be wh e n
us i ng t h e De r ma j e t , i t i s h e l pf ul t o pl a c e a t o ngue
bl a de a ga i ns t t h e l at er al s ur f a c e of t he l o be . At t he
first s i gn of r e c ur r e nc e , a pr e s s ur e e a r r i ng s h o ul d be
a dde d t o t h e t r e a t me nt r e gi me n
Traumatic Injuries of the Pinna
I nj ur i e s o f t h e pi nna ar e c l a s s i f i e d a s f o l l o ws :
1. T r a uma t i c h e ma t o ma wi t h or wi t h o ut c e l l ul i t i s
o r pe r i c h o ndr i t i s
2. La c e r a t i o n wi t h o ut t i s s ue l o s s
3. La c e r a t i o n wi t h s ki n o r c a r t i l a ge l o s s , o r bo t h .
4. To t a l a mput a t i o n o f t h e pi nna .
Hematoma of the Pinna
A h e ma t o ma of t h e pi nna i s c a us e d by bl unt
t r a uma a nd mo s t of t e n a f f e c t s t h e l at er al s ur f a c e ( Fi g.
2 0 - 2 D ) . I t s h o ul d be dr a i ne d a s s o o n a s po s s i b l e
b e f o r e t h e c l ot o r ga ni z e s . An o r ga ni z e d h e ma t o ma
r e qui r e s mo r e e x t e ns i v e s ur ge r y .
Aim
To dr a i n t h e h e ma t o ma , pr e v e nt r e a c c umul a t i o n,
a v o i d s e c o nda r y c e l l ul i t i s o r pe r i c h o ndr i t i s , a nd pr e -
v e nt t h e de f o r mi t y c a us e d b y o r ga ni za t i o n o f t he
h e ma t o ma ( c a ul i f l o we r e a r ) .
Highl ights
1. T h e mo s t i mpo r t a nt s t e p i s t h e pl a c e me nt of a
we l l - mo l de d dr e s s i ng t o pr e v e nt a r e c ur r e nc e
2 . T h e i nc i s i o n s h o ul d b e h i dde n o r s h o ul d r un
f a vo r a bl y wi t h t h e a n a t o my o f t h e pi nna .
3. A dr a i n ma y be ne c e s s a r y wh e n t r e a t i ng a l a r ge
h e ma t o ma .
Pitfalls
1. Re c u r r e n c e o f t h e h e ma t o ma o wi ng t o a n in-
a de qua t e dr e s s i ng.
Instruments and Suppl ies
No . 11 o r No . 15 s c a l pe l a nd h a ndl e .
Cur v e d h e mo s t a t ( mo s qui t o )
0. 25- i n P e nr o s e dr a i n ( o pt i o na l )
Co t t o n ba l l s .
P o v i do ne - i o di ne ( Be t a di ne ) o i nt me nt
50- 50 mi x t ur e o f mi ne r a l oil a nd Be t a di ne s o l ut i o n
( o pt i o na l ) .
4 x 4 " F l uf f s . "
2-in r ol l e d b a n d a g e s
2- 0 ny l o n or pr o l e ne on a l a r ge c ut t i ng ne e dl e
Hi b i c l e ns o r Be t a di ne s c r ub.
No r ma l s a l i ne i r r i ga t i ng s o l ut i o n.
Procedure
Li do c a i ne 1% wi t h 1 : 1 00, 000 e pi ne ph r i ne c a n be
us e d a s a f i el d b l o c k or i nj e c t e d l oc a l l y. T h e e a r i s
pr e pa r e d wi t h Hi b i c l e ns or Be t a di ne s c r ub. A ve r t i c a l
c ur vi l i ne a r i nc i s i o n i s ma d e o v e r o r a l o ng t h e s i de o f
t he h e ma t o ma ( us ua l l y unde r e i t h e r t he h e l i c a l o r
a nt h e l i c a l f ol d t o c a mo uf l a g e i t ) . I t i s be t t e r t o ma k e
a n i nc i s i o n l a r ge e n o u g h f or go o d dr a i na ge a nd deal
wi t h t h e r e s ul t a nt s c a r l at er t h a n t o be f a c e d wi t h a
pe r s i s t e nt o r r e c ur r e nt h e ma t o ma a nd s e c o nda r y
pe r i c h o ndr i t i s . A c ur v e d mo s qui t o h e mo s t a t ma y be
us e d t o o pe n up a ny l o c ul a t i o ns . A c ul t ur e of t he
h e ma t o ma s h o ul d be t a ke n i f c e l l ul i t i s i s pr e s e nt .
344 Pi as i i c S ur ge r y of t h e Pi nna
T h e h e ma t o ma c a n t h e n b e i r r i ga t e d ge nt l y wi t h
s t e r i l e no r ma l s a l i ne . A >/i-in P e nr o s e dr a i n or r ub b e r
b a nd dr a i n s h o ul d b e us e d f or e x t e ns i v e h e ma t o ma s .
S ki n s ut ur e s s h o ul d t h e n a ppr o x i ma t e t h e s ki n o f
l a r ge i nc i s i o ns but stil l a l l o w a d e q u a t e dr a i na ge . Ne xt
c o t t o n ba l l s s a t ur a t e d wi t h Be t a di ne o i nt me nt ( or a
5 0- 5 0 mi x t ur e o f Be t a di ne s o l ut i o n a nd mi ne r a l oil )
a r e f o r me d i nt o s h a pe s t ha t pr e c i s e l y c o r r e s po nd t o
t he f ol ds o f t h e pi nna o v e r l y i ng t he h e ma t o ma . An
a ddi t i o na l pi e c e of c o t t o n s h o ul d be mo l de d t o fit
i nt o t h e po s t a ur i c ul a r c r e a s e ( Fi g. 2 0 - 2 E ) . An e xa c t
fit i s ne c e s s a r y t o pr e v e nt r e a c c umul a t i o n of t he
h e ma t o ma s . T h e pi e c e s o f c o t t o n a r e h e l d i n pl a c e
wi t h t h r o ug h - a nd- t h r o ug h 2 - 0 ny l o n o r pr o l e ne ma t -
t r e s s s ut ur e s ; us ua l l y t wo wi l l s uf f i c e . A ma s t o i d
dr e s s i ng of " F l uf f s " a nd a 2- i n r ol l ed b a nda g e a r e
t he n a ppl i e d.
Postoperative Care
T h e pa t i e nt s h o ul d b e pl a c e d o n a n or al a nt i bi o t i c
t hat c o v e r s f or s ki n f l or a, pr e do mi na nt l y Slnp/n/locot' -
cus. T h e ma s t o i d dr e s s i ng a nd c o t t o n ba l l s c a n be
r e mo v e d a f t e r t wo da y s a nd t h e pi nna i ns pe c t e d. I f
t h e r e h a s b e e n no r e a c c umul a t i o n, no f ur t h e r ma s t o i d
dr e s s i ng i s ne e de d a nd t h e c o t t o n b o l s t e r s a r e re-
mo v e d i n t wo t o t h r e e da y s . I f r e a c c umul a t i o n h a s
o c c ur r e d, t h e h e ma t o ma mus t b e dr a i ne d a ga i n, a nd
t he s a me t y pe o f pr e c i s e c o t t o n pa c ki ng wi t h n
ma s t o i d dr e s s i ng i s r e a ppl i e d. I f t h e r e i s e v i de nc e of
pe r i c h o ndr i t i s , c ul t ur e s s h o ul d b e t a ke n a nd pa r e n-
t er al a nt i b i o t i c s s t a r t e d. A P e nr o s e dr a i n or a
t h r o ug h - a nd- t h r o ug h s uc t i o n i r r i ga t i on s y s t e m ma v
be ne c e s s a r v . I f t h e r e i s e v i de nc e o f c a r t i l a ge ne c r o s i s ,
wi de de b r i de me nt o f ne c r o t i c sof t t i s s ue a nd c a r t i l a ge
i s ne e de d. T h e r e c o ns t r uc t i o n o f a ny de f e c t s r e s ul t i ng
f r om pe r i c h o ndr i t i s i s s i mi l a r t o t hat pe r f o r me d af t er
ne o pl a s m r e s e c t i o n ( de s c r i b e d b e l o w) .
Laceration without Tissue Loss
T h e e a r ' s p r o mi n e n t a nd e x p o s e d l o c a t i o n o n t h e
h e a d r e nde r s i t v ul ne r a b l e t o l a c e r a t i o ns . Co mp l e x
l a c e r a t i o ns s h o ul d be c a r e f ul l y e x a mi n e d f or f or ei gn
b o di e s a nd a n y e v i de nc e o f s of t t i s s ue l o s s . T h e s ki n
i s de ns e l y a d h e r e n t t o t h e unde r l y i ng c a r t i l a ge , a nd
a n y f ul l - t h i c kne s s i nj ur y o f t h e de r mi s wil l e x po s e
t h e c a r t i l a ge t o t h e r i s k of i nf e c t i o n. Al l f ul l - t h i c kne s s
l a c e r a t i o ns s h o ul d b e r e pa i r e d.
Aim
To r e pa i r a l a c e r a t i o n o f t h e pi nna .
Highl ights
1. I nt r a c a r t i l a gi no us s ut ur e s a r e of t e n ne c e s s a r y .
2 . Appa r e nt l y no nvi t a l t i s s ue s h o ul d b e s a v e d
wh e n e v e r po s s i b l e . If a c u t a n e o u s l i nk o f s ki n per-
s i s t s , t h e s ki n of t h e pi nna h a s a r e ma r ka b l e abt l i t .
1
t o wi t h s t a nd v a s c ul a r c o mp r o mi s e . T h e no nvi t a l tis-
s ue wi l l de ma r c a t e s e ve r a l da y s l a t e r a nd c a n b e
de b r i de d t h e n.
3. Us e of a s t e nt wi t h e x t e r na l a udi t o r y c a na l
l a c e r a t i o ns t o pr e v e nt s t e no s i s .
Pitfalls
1. P o s t - t r a uma t i c t a t t o o i ng due t o i nc o mpl e t e de -
b r i de me nt .
2. I mpr e c i s e c l o s ur e r e s ul t i ng i n p r o mi n e n t s c a r -
r i ng or i r r e gul a r i t i e s i n t he c a r t i l a ge f o r ma t i o n.
3. Fa i l i ng t o r e c o gni z e a n e x t e r na l a udi t o r y c a na l
l a c e r a t i o n.
Instruments
A b a s i c pl a s t i c s pa c k.
Procedure
Us ua l l y 17, l i do c a i ne wi t h 1: 100, 000 e pi ne ph r i ne
c a n be us e d. I f t h e r e a r e f l aps or r e gi o ns wi t h a
c o mp r o mi s e d b l o o d s uppl y , 1V< l i do c a i ne wi t h o ut
e pi ne ph r i ne s h o ul d b e us e d. S i mp l e l a c e r a t i o ns o l
t h e s ki n o f t he pi nna s h o ul d be me t i c ul o us l y c l e a ne d.
It i s i mpo r t a nt t o r e mo v e all de b r i s t o pr e v e nt po s t -
t r a uma t i c t a t t o o i ng. T h e l a c e r a t i o n s h o ul d b e c l o s e d
wi t h 6- 0 c h r o mi c or 6- 0 ny l o n s ut ur e . I f ne c e s s a r y ,
s u b c u t a n e o u s s ut ur e s a l s o a r e us e d t o r e duc e t e ns i o n
a nd e v e r t t h e s ki n e dge s ; 5- 0 Vi c r vl o r c h r o mi c
. s ut ur es wo r k bes t f or t hi s ( Fi g. 20- 21, C). S ut ur e s ol
6- 0 c h r o mi c a r e pl a c e d t h r o ugh t h e s ki n di f f e r e nt l y
f r om 6- 0 ny l o n s ut ur e s . Ch r o mi c s ut ur e s us ua l l y ar e
not r e mo v e d a nd o nl y s e r v e t o a ppr o x i ma t e t h e s ki n
e dge s , r a t h e r t h a n dr a wi ng t h r o ugh t h e s ub c ut a -
ne o us t i s s ue ; t h e y a r e i ndi c a t e d wh e n t h e r e i s no
t e ns i o n o n t h e wo u n d e dg e s . Ei t h e r r unni ng l o c ke d
s ut ur e s o r s i mpl e i nt e r r upt e d s ut ur e s c a n b e us e d.
La c e r a t i o ns i nv o l v i ng c a r t i l a ge c a n be c l o s e d by
di r e c t l y s ut ur i ng t he c a r t i l a ge t o ge t h e r wi t h 5- 0 Vi -
c r yl . Unl e s s t h e c a r t i l a ge i s gr o s s l y c o nt a mi na t e d i t
do e s no t ne e d de b r i di ng. Ho r i zo nt a l ma t t r e s s s ut ur e s
i n t h e pl a ne o f t h e c a r t i l a ge pr o v i de a c c ur a t e r e a p-
pr o x i ma t i o n.
La c e r a t i o ns t h r o ug h t h e e x t e r na l a udi t o r y c a na l
a r e t r e a t e d i ni t i a l l y wi t h a ba c i t r a c i n g a uz e pa c k. T h e
pa c k c a n be r e mo v e d i n five t o s e v e n da y s , a t wh i c h
Pl a s t i c S ur g e r y of t h e P i nna 345
t i me a s t e nt mu c h l i ke t hat for a h e a r i ng ai d c a n be
pl a c e d t o pr e v e nt po s t - t r a uma t i c s t e no s i s o f t h e c a na l
( Fi g 2 0 - 2 H) . A c e nt r a l h o l e s h o ul d be dr i l l e d t o a l l o w
h e a r i ng. T h e s t e nt s h o ul d be wo r n f or t h r e e t o s i x
we e k s , d e p e n d i n g o n t h e s e v e r i t y o f t h e i nj ur y
Ba c i t r a c i n i s a ppl i e d t o t h e l a c e r a t i o n t o pr e v e nt
c r us t i ng. If t h e l a c e r a t i o n i s e x t e ns i v e , a ma s t o i d
dr e s s i ng wi t h c o t t o n mo l di ng ( l i ke t ha t us e d for
pi nna h e ma t o ma s but wi t h o ut t h e ma t t r e s s s t a y
s ut ur e s ) s h o ul d be a ppl i e d a nd wo r n for t wo t o t h r e e
da y s .
Laceration with Skin or
Cartilage Loss
Re c o ns t r uc t i o n o f t h e pi nna af t er l a c e r a t i o ns wi t h
t i s s ue l o s s i s s i mi l a r t o t ha t af t er t h e r e s e c t i o n of a
n e o p l a s m ( de s c r i b e d b e l o w) .
Total Amputation of the Pinna
F o r t una t e l y , t ot al o r s ubt o t a l a mput a t i o n o f t h e
pi nna i s a r a r e o c c ur r e nc e . Ca s e s i n wh i c h t h e a m-
put a t e d pi e c e i s mi s s i ng o r gr o s s l y c o nt a mi na t e d
o b v i a t e t h e ne e d f or i mme di a t e r e c o ns t r uc t i o n. D e -
l a y e d t ot al a ur i c ul a r r e c o ns t r uc t i o n o r pr o s t h e t i c r e-
h a bi l i t a t i o n a r e o ut s i de t h e s c o pe o f t h i s t e xt . Wh e n
l e s s t h a n 5 0 % o f t h e t i s s ue o f t h e pi nna h a s b e e n
l os t , a nd t h e a mput a t e d pa r t h a s b e e n s a v e d, r e c o n-
s t r uc t i o n of t he r e mna nt i s s i mi l a r t o t ha t pe r f o r me d
af t er ne o pl a s m r e s e c t i o n.
Aim
To r e a t t a c h t he a mput a t e d por t i on o f t he pi nna
H i g h l i g h t s
1. I f t h e a mput a t e d pi e c e i s a va i l a bl e , r e i mpl a n-
t a t i on s h o ul d b e a t t e mpt e d unl e s s t h e pa t i e nt ' s me d-
i cal c o ndi t i o n c o nt r a i ndi c a t e s a l e ngt h y ge ne r a l a n-
e s t h e t i c .
2. Cl o s e po s t o pe r a t i v e f o l l o w- up i s n e e d e d t o
wa t c h f or i nf e c t i o n, v e n o u s c o nge s t i o n, a nd ne c r o s i s .
Pitfalls
1. T h e l a r ge r t h e a mp u t a t e d pa r t , t h e gr e a t e r i s
t he l i ke l i h o o d of pa r t i a l or t ot al l o s s .
2 . V e n o u s c o ng e s t i o n ma y not b e pr e v e nt a b l e
e v e n wi t h pi e - c r us t i nc i s i o ns o r l e e c h e s .
3 . T h e c a r t i l a ge s ke l e t o n wi l l no t b e a s s h a r p o r
we l l - de f i ne d wh e n r e - e pi t h e l i a l i ze d wi t h t he t h i c ke r
po s t a ur i c ul a r s ki n.
Instr uments
A b a s i c pl a s t i c pa c k pl us a de r ma b r a de r .
Mi c r o v a s c ul a r i ns t r ume nt s .
Procedure
Ge ne r a l a ne s t h e s i a us ua l l y i s i ndi c a t e d o wi n g t o
t he l e ngt h o f t h e r e pa i r . Wh e n t h e a mput a t e d pa r t i s
a va i l a bl e i t s h o ul d be r i ns e d i n c ol d s a l i ne , wr a p p e d
i n a mo i s t c o t *o n g a uz e , pl a c e d i n a s e a l a b l e pl a s t i c
ba g, a nd t h e n pa c ke d i n i c e . Wh e n de a l i ng wi t h a n
a mput a t e d pi nna , i t i s i mpo r t a nt t o l et t h e pa t i e nt
a nd f a mi l y k n o w t he po o r pr o g no s i s e v e n i n t h e be s t
o f c i r c ums t a nc e s .
I n c l e a n a mput a t i o ns wi t h o ut mu c h c r us h i ng o r
a v ul s i o n o f t i s s ue , mi c r o v a s c ul a r r e a t t a c h me nt o f a n
a mput a t e d pi nna ma y be i ndi c a t e d. I f t h i s s e r v i c e i s
a va i l a bl e i t i s pr o b a b l y a wo r t h wh i l e e f f or t .
If o nl y a s ma l l pi e c e ( 1 t o 2 cm of t i s s ue or t he
h e l i c a l r i m) h a s b e e n a mp u t a t e d i t c a n s i mpl y be
r e a t t a c h e d, but r e a t t a c h me nt of a t ot a l l y a mput a t e d
pi nna wi t h o ut r e - e s t a b l i s h me nt o f t h e c i r c ul a t i o n b y
mi c r o v a s c ul a r s ur ge r y o f t e n r e s ul t s i n a t ot al l os s of
t h e pi nna s e c o n d a r y t o v a s c ul a r c o ng e s t i o n. Ho w-
e ve r , i f t h e r e i s a s ma l l c u t a n e o u s br i dge l i nki ng t h e
pi nna t o t h e h e a d, s i mpl e r e a t t a c h me nt i s a dv a nt a -
ge o us . Me di c i na l l e e c h e s h a v e b e e n us e d t o r e duc e
t he v e n o u s c o ng e s t i o n.
I n s o me c a s e s , wh e n t h e pi nna h a s b e e n t ot a l l y
a mput a t e d a nd mi c r o v a s c ul a r r e pa i r i s no t a va i l a bl e
o r i ndi c a t e d, t he c a r t i l a gi no us f r a me wo r k ma y b e
s a l v a ge d by de r ma b r a di ng al l o f t h e e pi de r mi s f r om
t h e c a r t i l a gi no us s ke l e t o n a nd b ur y i ng t h e pi nna i n
a po s t a ur i c ul a r po c ke t f or t h r e e t o f our we e ks . T h e
c a r t i l a gi no us s ke l e t o n c a n t h e n b e " r e l e a s e d " f r om
t hi s po c ke t a n d a l l o we d t o s l o wl y r e - e pi t h e l i a l i ze .
I f o nl y a po r t i o n o f t h e pi nna h a s b e e n a mput a t e d,
al l o f t h e s of t t i s s ue o v e r l y i ng b o t h s ur f a c e s o f t h e
a mput a t e d s e g me n t i s r e mo v e d , s pa r i ng t h e per i -
c h o ndr i um; t h e c a r t i l a ge s e g me n t i s t h e n r e a t t a c h e d
t o t h e r e ma i ni ng pi nna wi t h ma t t r e s s s ut ur e s t o
r e a ppr o x i ma t e t h e c a r t i l a ge . T h e de nude d c a r t i l a ge
s e g me n t i s t h e n bur i e d i n a po s t a ur i c ul a r po c ke t ,
wh i c h h a s b e e n c r e a t e d b y i nc i s i ng t h e po s t a ur i c ul a r
s ki n, f o l l o we d b y wi de unde r mi ni ng ( Fi g. 2 0 - 3 )
An o t h e r me t h o d o f s a l v a gi ng t h e c a r t i l a gi no us
s ke l e t o n o f t h e a mput a t e d e a r i s t o r e mo v e t h e s ki n
Pl a s t i c S ur g e r y o f t h e P i nna 347
f r om t h e me di a l s ur f a c e o f t he pi nna a nd pe r f or a t e
t i l e c a r t i l a ge . The po s t a ur i c ul a r s ki n i s t h e n r e mo v e d
a nd t h e e a r i s r e a t t a c h e d by s ut ur i ng t h e h e l i c a l r im
t o t h e f r ee ma r gi n o f r e ma i ni ng po s t a ur i c ul a r s ki n
( Fi g 2 0 - 4 ) . " P i e - c r us t " i nc i s i o ns o r me di c i na l l e e c h e s
ma y be ne c e s s a r y i f v e n o u s c o ng e s t i o n i s a pr o b l e m.
T h e l as t t wo me t h o d s r e qui r e t ha t t h e h e l i c a l r i m
be l i f t ed af t er t h r e e t o f our we e k s by i nc i s i ng t h e
po s t a ur i c ul a r s ki n. T h e de f e c t l eft i n t h e po s t a ur i c ul a r
a r e a c a n s o me t i me s be c l o s e d by pr i ma r y c l o s ur e . A
s pl i t - t h i c kne s s or f ul l - t h i c kne s s s ki n gr af t f r om t h e
o ppo s i t e po s t a ur i c ul a r r e gi on o r f r om t h e s upr a c l a -
vi c ul a r a r e a a l s o c a n be us e d. An o t h e r me t h o d i s t o
pl a c e a f os s a t i s s ue e x p a n d e r b e h i nd t h e ear , a nd t o
us e t h i s e x p a n d e d s ki n t o r est ir f ace t he po s t a ur i c ul a r
ar ea.
I f t h e po s t a ur i c ul a r a r e a i s b a dl y i nj ur e d a nd not
s ui t a b l e f or o ne o f t h e a b o v e me t h o d s o f r e c o ns t r uc -
t i on, t h e pi nna c a n b e " b a n k e d " unde r c e r vi c a l s ki n
Th i s i s d o n e by r e mo v i ng t h e s of t t i s s ue f r om t he
c a r t i l a ge ; ma ki ng a po c ke t unde r a c e r vi c a l s ki n f l ap,
a nd l e a v i ng i t t h e r e unt i l t h e po s t a ur i c ul a r s ki n h a s
h e a l e d. A c r e s c e nt - s h a pe d t i s s ue e x pa nde r c a n t h e n
be pl a c e d i n t he po s t a ur i c ul a r / ma s t o i d r e gi o n a nd
s l o wl y e x p a n d e d o v e r f our t o six we e k s unt i l t wi c e
a s mu c h s ur f a c e a r e a i s e x p a n d e d ( s e c Fi g. 2 0- 4 / 3 ) .
T h e " b a n k e d " c a r t i l a ge s ke l e t o n i s r e mo v e d f r om
b e ne a t h t h e c e r vi c a l f l ap a nd pl a c e d i nt o t h e e x -
pa nde d po c ke t . Hi g h - v a c uum s uc t i o n i s ne c e s s a r y t o
o bt a i n g o o d a ppo s i t i o n o f t he s ki n t o t h e i nt e r s t i c e s
o f t h e c a r t i l a ge .
Postoperative Car e
S t e r o i ds , h e pa r i n, a nt i bi o t i c s , pi e - c r us t i nc i s i o ns
a nd, l a t e l y, me di c i na l l e e c h e s h a v e all b e e n a dv o -
c a t e d i n t h e c a r e o f t h e r e i mpl a nt e d pi nna . Me t i c u-
l ous wo u n d c a r e wi t h ba c i t r a c i n a nd Ada pt i c ga uz e
i s ne c e s s a r y . Of t e n t h e r e i s de - e pi t h e l i a l i za t i o n of t he
a mp u t a t e d par t , but wi t h ge nt l e de b r i de me nt t h e
pi nna us ua l l v c a n r e - e pi t h e l i a l i ze . I f t h e r e i mpl a nt a -
t i on i s s uc c e s s f ul , t h e pa t i e nt mus t be c a ut i o ne d t hat
t h e n e w c i r c ul a t i o n ma y no t b e r e s i l i e nt e n o u g h t o
b e i mme di a t e l y e x p o s e d t o e x t r e me s o f t e mpe r a t ur e
o r i nj udi c i o us l y e x po s e d t o t h e s un.
Neoplasms of the Pinna
Th e pi nna is a f r e que nt s i t e of ba s a l cel l a nd
s q u a mo u s cel l c a r c i no ma s a nd, l e s s f r e que nt l y , ma -
l i gna nt me l a n o ma s . Al l but s h a v e d, p un c h e d , o r
c ur e t t e d b i o ps i e s s h o ul d b e r e pa i r e d. T h e t e c h ni que s
us e d t o r e c o ns t r uc t de f e c t s o f t h e pi nna a f t e r r e s e c -
t i on of a ne o pl a s m c a n a l s o be us e d t o r e c o ns t r uc t
t h e pi nna a f t e r a l a c e r a t i o n wi t h t i s s ue l o s s
Aim
To r e c o ns t r uc t t he pi nna af t er r e s e c t i o n of a ne o -
pl a s m.
Highlights
1. Ge nt l e h a ndl i ng of t h e t i s s ue s i s ne c e s s a r y t o
r e duc e o pe r a t i v e t r a uma .
2 . S ma l l de f e c t s a r e r e pa i r e d b y pr i ma r y c l o s ur e
o r c o mp o s i t e gr af t .
3. La r ge r de f e c t s mo s t of t e n a r e r e pa i r e d wi t h a
po s t a ur i c ul a r pe di c l e d gr af t .
4. T h e l e s s c o mpl e x t h e r e pa i r , t h e gr e a t e r i s t he
l i ke l i h o o d o f go o d r e s ul t s .
5. Al l ma r g i ns o f r e s e c t i o n s h o ul d be h i s t o l o gi c a l l y
e x a mi n e d .
Pitfalls
1. I mpr e c i s e c l o s ur e ma v l e a d t o a c o s me t i c de f or -
mi t y.
2. A c o mpo s i t e gr af t ma y be l ost i f i t i s t oo l a r ge
( > 1.5 c m) .
3. A pi nna ma y " c u p " af t er a we d g e r e s e c t i o n i f
we d g e s o f s ki n a nd c a r t i l a ge a r e not r e mo v e d a l o ng
t he a nt h e l i c a l f ol d.
Instruments
T h e i ns t r ume nt s l i s t ed b e l o w f or m t he ba s i c s of a
pl a s t i c s t r ay us e d f or mo s t s of t t i s s ue s ur ge r y o f t he
h e a d a nd ne c k. T h e s e i ns t r ume nt s wil l be us e d for
t h e pr o c e dur e s de s c r i b e d i n t he r est of t h i s c h a pt e r .
No . 11 a nd No 15 s c a l pe l b l a de s a nd h a ndl e s
Me d i u m a n d f i ne ne e dl e h o l de r s .
0. 5 - mm o ph t na l mi c f o r c e ps
Br o wn - Ad s o n f o r c e ps .
No . 3 s i ngl e or do ub l e s ki n h o o ks .
No . 2 S e n n r e t r a c t o r s .
S t o r z " s t i t c h " s c i s s o r s .
HC UR K 2 < M
Pl a s t i c S ur ge r y o f t h e P i nna 349
Cur v e d a nd s t r a i gh t iris s c i s s o r s .
S ma l l Me t z e n b a u m s c i s s o r s
T e n o t o my s c i s s o r s
S ut ur e s : 4- 0 a nd 5- 0 Vi c r y l , 4- 0 a nd 6- 0 ny l o n, 6- 0
c h r o mi c .
Ma r ki ng pe n.
Co t t o n- t i ppe d a ppl i c a t o r s .
Dr e s s i ng: Ti nc t ur e o f b e nz o i n, S t e r i - S t r i ps , 4 x 4
" F l uf f s , " 2- i n r ol l e d b a nda g e , c o t t o n ba l l s , a nd
Be t a di ne o i nt me nt .
Procedure
D e p e n d i n g o n t h e e x t e nt o f t h e r e c o ns t r uc t i o n,
e i t h e r l oc a l a ne t h e s i a wi t h 1% l i do c a i ne a n d 1 : 1 00, 000
e pi ne ph r i ne o r ge ne r a l a ne s t h e s i a c a n b e us e d
Af t e r t h e r e s e c t i o n of a ne o pl a s m, t h e pi nna c a n
b e r e c o ns t r uc t e d b y ma n y me t h o d s , l i mi t e d o nl y b y
t he s ur g e o n' s i ma gi na t i o n a nd i nge nui t y . T h e f ol l ow-
i ng di s c us s i o n, wh i c h i s no t i nt e nde d t o b e e nc y -
c l o pe di c , o ut l i ne s me t h o d s t ha t h a v e wo r ke d wel l
o v e r t h e y e a r s a nd t hat a r e b a s e d o n ge ne r a l pr i nc i -
pl e s of f l ap de s i gn.
Af t e r r e mo v i ng t h e ne o pl a s m, al l ma r gi ns mus t
b e e x a mi n e d h i s t o l o gi c a l l y .
T h e pi nna c a n be r e c o ns t r uc t e d i n t h r e e wa v s : ( 1)
pr i ma r y c l o s ur e , ( 2) a c o mpo s i t e gr af t f r om t h e o t h e r
ear , a nd ( 3) a pe di c l e d s ki n/ c a r t i l a ge f l ap.
Prunaru Closure. Wh e n l e s s t h a n 307r of t h e pi nna
h a s b e e n e x c i s e d, t h e de f e c t o f t e n c a n b e c l o s e d
pr i ma r i l y , e s pe c i a l l y i t i t i nv o l v e s t h e uppe r a nd
mi ddl e po r t i o ns o f t h e pi nna ( Fi g. 2 0 - 5 / 1 . B). Wh e n
c l o s i ng a de f e c t pr i ma r i l y , i t i s us ua l l y ne c e s s a r y t o
us e a nv of a va r i e t y of r e l e a s i ng i nc i s i o ns a l o ng t h e
a nt h e l i c a t f ol d a nd c o nc h a l b o wl t o a l l o w f or t h e
a d v a n c e me n t o f a dj a c e nt t i s s ue . T h e r i gi d car t i l agi -
no us f r a me wo r k o f t h e pi nna , t h e de ns e l y a dh e r e nt
s ki n, a nd t h e l a c k o f s u b c u t a n e o u s t i s s ue h i nde r t he
c l o s ur e o f e v e n s ma l l de f e c t s . Wi t h o ut t h e s e i nci -
s i o ns , c l o s ur e o f t h e de f e c t ma y c a us e c u p p i n g o f t h e
pi nna . Of t e n, s ma l l we d g e s o f c o nc h a l b o wl c a r t i l a ge
mus t b e r e mo v e d s o t ha t pr o pe r c l o s ur e c a n b e
o b t a i ne d. Cl o s ur e i s a c c o mpl i s h e d wi t h i nt e r r upt e d
5- 0 Vi c r y l s ut ur e i n t h e c a r t i l a ge a nd a c u t a n e o u s
l a ye r o f r unni ng l o c ke d 6- 0 c h r o mi c o r i nt e r r upt e d 6-
0 ny l o n s ut ur e .
Composite Graft. An o t h e r s a t i s f a c t o r y me t h o d of
r e pa i r i ng s ma l l de f e c t s o f t he pi nna ( no gr e a t e r t h a n
3 c m) i s t o us e a c o mp o s i t e gr af t f r om t h e o ppo s i t e
e a r . A t h r o ug h - a nd- t h r o ug h gr af t up t o 1. 5 cm i n
s i ze c a n b e h a r v e s t e d f r om t h e d o n o r e a r . T h e s i ze
of t h e gr af t i s us ua l l y h a l f t h e s i ze of t h e de f e c t
t ha t i s , f or a 2- c m de f e c t a 1-cm c o mp o s i t e gr af t is
h a r v e s t e d. T h e d o n o r s i t e i s c l o s e d pr i ma r i l y a s
de s c r i b e d a b o v e . T h e c o mp o s i t e gr af t i s t h e n s ut ur e d
i n pl a c e wi t h a mi ni ma l n u mb e r of s ut ur e s , s e c ur i ng
t h e c a r t i l a ge wi t h 5- 0 Vi c r yl a nd c l o s i ng t h e s ki n wi t h
6- 0 c h r o mi c o r ny l o n s ut ur e . T o o ma n y s ut ur e s c a n
c o mp r o mi s e t h e vi a bi l i t y o f t h e gr af t . Co mp o s i t e
gr af t s of t e n unde r g o e pi de r mo l y s i s wi t h di s c o l o r a -
t i on a nd bl i s t e r f o r ma t i o n, but us ua l l y r e - e pi t h e l i a l i ze
i f i nf e c t i o n i s a v o i de d.
Pedicled Skin Flap. Fo r l a r ge r de f e c t s , a s ki n f l ap
b a s e d e i t h e r a nt e r i o r l y o r po s t e r i o r l y o n t h e po s t a u-
r i c ul a r s ki n i s e l e v a t e d a n d s ut ur e d i nt o t h e de f e c t
( Fi g. 2 0 - 5 C, D). I f t h e de f e c t h a s b e e n c r e a t e d by
r e s e c t i o n of a ne o pl a s m or a t r a uma t i c t i s s ue l os s , an
a nt e r i o r l y b a s e d f l ap i s no t f e a s i bl e . T h e b l o o d s uppl y
i s be t t e r wh e n t h e f l ap i s b a s e d po s t e r i o r l y , but
a nt e r i o r l y b a s e d f l a ps us ua l l y do no t r e qui r e a s e c -
o nda r y t a k e d o wn pr o c e dur e . T h e l e ngt h - t o - wi dt h
r at i o i s us ua l l y l o w (1: 1 t o 2: 1) b e c a us e of t h e c l o s e
pr o xi mi t y of t h e d o n o r s i t e . A pi e c e of c o nt r a l a t e r a l
c o nc h a l b o wl c a r t i l a ge o r c os t a l c a r t i l a ge c a n be
pl a c e d un d e r t h e f l a p pr i ma r i l y , o r s e c o nda r i l y wh e n
t h e f l ap i s t a ke n d o wn ( Fi g. 2 0 - 5 E) . For s ma l l de f e c t s
t h e us e o f c a r t i l a ge i s no t ne c e s s a r y . T h e po s t a ur i c -
ul ar s ul c us of t e n c a n be pr e s e r v e d by l e a vi ng a s t r i p
o f po s t a ur i c ul a r s ki n i nt a c t wh e n de v e l o pi ng t h e f l ap.
T h e f r e e ma r g i n o f s ki n o n t h e me di a ) s ur f a c e o f t h e
pi nna i s s ut ur e d t o t h e f r ee ma r gi n of t h e po s t a ur i c -
ul ar s ki n. T h e l e a di ng e dg e o f t h e e l e v a t e d fl ap i s
s ut ur e d t o t h e f r ee ma r gi n of t h e l at er al s ki n of t he
pi nna . Af t e r t h r e e o r f our we e k s t h e pe di c l e d f l ap
c a n be s e pa r a t e d f r o m t h e po s t a ur i c ul a r s ki n a nd
r ol l ed a r o und t o ma k e a n e w h e l i c a l r i m ( Fi g. 2 0 - 5 F ,
C) . I f t h e h e l i c a l f ol d i s not wel l de f i ne d, s ma l l c o t t o n
bo l s t e r s c a n be pl a c e d o n t h e l at er al s ur f a c e o f t he
pi nna a nd s ut ur e d i n pl a c e wi t h 4- 0 ny l o n t o h e l p
r e c r e a t e t h i s po r t i o n. S u b c u t a n e o u s a nd c a r t i l a gi no us
s ut ur e s a r e 5- 0 Vi c r vl , wi t h 6- 0 c h r o mi c o r nyl on
us e d f or t h e c ut a ne o us l a y e r . T h e do no r s i t e us ua l l y
c a n b e c l o s e d pr i ma r i l y wi t h e x t e ns i v e unde r mi ni ng,
but a s ki n gr af t ma y be ne c e s s a r y .
De f e c t s o f t h e c o nc h a l b o wl c a n be c l o s e d pr i ma r i l y
i f t h e y a r e s ma l l . Fo r a l a r ge r de f e c t , a f ul l - t h i c kne s s
po s t a ur i c ul a r s ki n gr af t wo r k s we l l . La r ge de f e c t s
a l s o ma y be r e pa i r e d wi t h a po s t a ur i c ul a r pe di c l e d
s ki n f l ap, wh i c h i s e l e v a t e d a nd l ai d t h r o ugh a slit
ma de t h r o ugh t h e c o nc h a l c a r t i l a ge ( Fi g. 2 0 - 6 / 1 ) . T h e
f l ap i s s ut ur e d a nt e r i o r l y , s upe r i o r l y , a nd i nt e r i or l y,
l e a v i ng t h e po s t e r i o r t h r o ugh - a nd- t h r o ugh sl it ( Fi g.
2 0 - 6 8 ) . Af t e r t h r e e o r f our we e k s t h e f l ap i s r e l e a s e d
a l o ng t h e po s t e r i o r sl it a nd t h e de f e c t i s c l o s e d
pr i ma r i l y ( Fi g. 2 0 - 6 C) .
Lo s s o f t h e e a r l obe c a n be r e pa i r e d by de s i gni ng
a b i l o b e d f l ap b a s e d a nt e r i o r l y , wh i c h i s l i f t ed a nd
f ol de d upo n i t s el f ( Fi g. 2 0 - 7 / 1 , B) . T h e d o n o r s i t e i s
350 Pl a s t i c S ur ge r y o f t h e P i nna
FIGURE 2(1-5
FIGURE 20 - 6
Pl a s t i c S ur g e r y o f t h e P i nna 353
c l o s e d pr i ma r i l y or wi t h a s ki n gr af t . Al t e r na t i v e l y ,
a n i nt e r i o r l y b a s e d f l ap i s e l e v a t e d a nd s ut ur e d t o
t he i nf e r i or e dg e o f t h e r e ma i ni ng pi nna . Af t e r t h r e e
t o f o ur we e k s t h e f l ap i s s e pa r a t e d i nt e r i or l y a nd
f ol de d u p o n i t s e l f ( Fi g. 2 0 - 7 C- E ) .
Postoperative Care
Ba c i t r a c i n o i nt me nt i s a ppl i e d t o t h e i nc i s i o ns . A
l i gh t ma s t o i d dr e s s i ng i s a ppl i e d t o pr e v e nt t he
pa t i e nt f r om di s t ur b i ng t he r e pa i r . T o o t i ght a dr e s s -
i ng mi gh t c o mp r o mi s e t he b l o o d s uppl y . T h e dr e s s -
i ng c a n be r e mo v e d i n a f e w da y s , a nd t h e ba c i t r a c i n
i s c o nt i nue d for a n o t h e r da y or t wo . I f a t a ke do wn
i s ne c e s s a r y , i t i s pe r f o r me d af t er t h r e e t o t o ur we e k s .
Af t e r t h e s e c o n d s t a ge of a pe di c l e d f l ap t h e r e i s
us ua l l y e d e ma o f t h e f l ap s i de o f t h e f l a p/ no r ma l s ki n
i nt e r f a c e ; t h i s ma k e s t h e r e pa i r mo r e no t i c e a b l e a nd
ma y t a ke s e ve r a l mo n t h s t o r e s o l ve . If, af t er s i x t o
ni ne mo n t h s , a de pr e s s e d s c a r h a s f o r me d ( t h i s c a n
be e s pe c i a l l y no t i c e a b l e on t h e h e l i c a l r i m) , a s ma l l
Z- pI a s t y c a n b e pe r f o r me d unde r l ocal a ne s t h e s i a .
Otoplasty
Ex c l udi ng mi c r o t i a , t h e t wo ge ne r a l t y pe s o f c o n-
ge ni t a l ma l f o r ma t i o ns o f t h e pi nna a r e l o p e a r s a nd
pr o mi ne nt e a r s . A l op e a r o c c ur s wh e n t h e s upe r i o r
po r t i o n of t he h e l i c a l r im i s f ol de d d o wn l i ke a h o o d
o v e r t h e r e s t o f t h e pi nna . T h e c a r t i l a ge i s f ol de d o n
i t s e l f a t a n a c ut e a ng l e . A pr o mi ne nt e a r c a n be due
t o e i t h e r t h e l a c k o f t h e a nt h e l i c a l f ol d o r a n o v e r pr o -
j e c l i ng c o nc h a l b o wl . T h e no r ma l a ngl e o f t h e e a r s
t o t h e s kul l i s 30 de gr e e s , a nd a no r ma l pr o j e c t i o n
f r om t h e po s t a ur i c ul a r a r e a t o t h e mi ddl e o ne - t h i r d
of t h e h e l i x i s 17 t o 20 mm. S ur gi c a l c o r r e c t i o n i s
pe r f o r me d wh e n a pa t i e nt or pa r e nt , i f t h e pa t i e nt i s
a c h i l d, r e que s t s i t a nd t h e r e a r e no me di c a l c o nt r a i n-
di c a t i o ns . Ch i l dr e n a r e us ua l l y o pe r a t e d o n b e f o r e
s t a r t i ng s c h o o l t o a v o i d a ny r i di c ul e t h e i r de f o r mi t y
mi gh t c a us e
Aim
To c o r r e c t t h e de f o r mi t y pr e s e nt i n e i t h e r a l o p o r
a p r o mi n e n t e a r .
Highlights
1. A dumb b e l l - s h a pe d po s t a ur i c ul a r i nc i s i o n is
us e d.
2. Ex c e s s c a uda h e l i x i s r e s e c t e d.
3. Ex c e s s c o nc h a l b o wl c a r t i l a ge i s r e s e c t e d a t t h e
e xt e r na l a udi t o r y me a t us .
Pitfalls
1. Co l l a ps e o f t h e e x t e r na l a udi t o r y c a na l ma y
o c c ur i f a n i ns uf f i c i e nt a mo u n t o f c o nc h a l b o wl car -
t i l a ge i s r e mo v e d wh e n t h e c o nc h a l - ma s t o i d s ut ur e s
a r e pl a c e d.
2. F a i l i ng' t o r e s e c t e x c e s s c a uda h e l i x.
3. A s h a r p- e dg e d a nt h e l i c a l f ol d ma y r e s ul t f r om
t oo de e p c r o s s h a t c h i ng f r o m t h e me di a l s ur f a c e o f
t h e e a r .
4 . I mpr e c i s e me a s ur i n g ma y r e s ul t i n a s y mme t r y
b e t we e n t h e t wo e a r s .
Instruments
A b a s i c pl a s t i c s pa c k.
Me t h y l e n e b l ue dy e .
A 2 2 - g a ug e ne e dl e .
Procedure
Ge ne r a l a ne s t h e s i a c o mmo n l y i s us e d s i nc e t h e
o pe r a t i o n i s mo s t of t e n pe r f o r me d o n c h i l dr e n; h o w-
e v e r , l oc a l a ne s t h e s i a c a n be us e d i n a dul t s . Ge ne r -
al l y, a pa t i e nt wi t h l o p or pr o mi ne nt e a r s pr e s e nt s
a s a y o u n g c h i l d f or c o r r e c t i v e s ur ge r y . Oc c a s i o na l l y ,
a n e wb o r n i nf a nt i s s e e n wi t h i n t h e first da y or t wo
of l ife wi t h a pr o mi ne nt or l op e a r , a nd i t i s po s s i bl e
t o c o r r e c t t h e de f e c t no ns ur gi c a l l y . I mme di a t e l y af t er
bi r t h ma t e r na l e s t r o g e n s a r e stil l pr e s e nt i n t h e i nf ant ,
wh i c h ma k e s t h e c a r t i l a ge sof t a nd ma l l e a b l e ; s t e nt -
i ng of t h e s e de f o r mi t i e s i n t h e ne o na t a l pe r i o d i s
s uc c e s s f ul unt i l t h e dr o p i n ma t e r na l e s t r o g e ns c a us e s
t h e c a r t i l a ge t o b e c o me fir m a nd r e s i s t a nt t o s t r uc t ur a l
c h a ng e . Us i ng S t e r i - S t r i ps a nd c o t t o n, t h e i nf a nt ' s
e a r i s f o r me d a nd t a pe d i nt o pr o pe r po s i t i o n. T h e
e a r mu s t b e t a pe d i n t hi s ma n n e r f o r . t wo t o t h r e e
mo n t h s ( Fi g. 2 0 - 8 / 1 , B).
Text continued on page 358
354 Pl a s t i c S ur ge r y o f t h e P i nna
PICURE 20 -8,
Pl a s t i c S ur g e r y o f t h e P i nna 355
FIGURE 20 -9.
FIGURE 20 -1(1
Pl a s t i c S ur g e r y o f t h e P i nna 357
FIGURE 20 -11
. I IU..LK J U J g C I } - III I Mf J 'Jllllcl
To c o r r e c t a l op e a r s ur gi c a l l y , a n i nc i s i o n i s ma d e
a l o ng t he me di a l e dg e o f t h e h e l i c a l r i m ( Fi g. 2 0 - 8 C) .
T h e sof t t i s s ue s o n b o t h s i de s o f t h e " h o o d e d " pi nna
ar e e l e v a t e d, t h us e x po s i ng t h e de f o r me d c a r t i l a ge .
Ve r t i c a l i nc i s i o ns a r e ma d e d o wn t h r o ug h t he h e l i x
al l t h e wa y t o t h e c o nc h a l b o wl , a l l o wi ng t h e f ol de d
c a r t i l a ge t o unf o l d a nd f l ar e o ut . A s t r ut of c o nc h a l
b o wl c a r t i l a ge i s s ut ur e d t o t h e me di a l s ur f a c e o f t h e
n e w h e l i c a l r i m t o gi v e mo r e s uppo r t ( Fi g. 2 0- 8 D, ) . I f
e n o u g h s ki n i s pr e s e nt , pr i ma r y c l o s ur e i s o b t a i ne d
wi t h 5- 0 Vi c r y l a nd e i t h e r 6- 0 c h r o mi c o r ny l o n
s ut ur e s ; o t h e r wi s e a po s t a ur i c ul a r f l ap l i ke t ha t us e d
f or r e pa i r o f pi nna de f e c t s i s e l e v a t e d a nd s ut ur e d
i nt o pl a c e . S ma l l b o l s t e r s o f c o t t o n s e c ur e d wi t h 4- 0
ny l o n s ut ur e h e l p gi ve de f i ni t i o n t o t h e h e l i c a l r i m
( Fi g. 2 0 - 8 E) .
T h e c o r r e c t i o n o f p r o mi n e n t e a r s d e p e n d s o n
wh e t h e r t h e de f o r mi t y i s o v e r pr o j e c t i o n o f t h e c o n-
c h a , l a c k of a n a nt h e l i c a l f ol d, or a c o mb i na t i o n of
t h e t wo . Mo s t p r o mi n e n t e a r s h a v e a n e l e me n t o f
bo t h de f o r mi t i e s .
A wo o d e n t o ng ue b l a de i s us e d t o me a s u r e t he
r i gh t a nd l eft e a r s a t t h e s t a r t o f t h e pr o c e dur e s o
t h a t s y mme t r y c a n b e o b t a i ne d ( Fi g. 2 0 - 9 A ) . Af t e r
t h e first e a r i s f i ni s h e d, its pr o j e c t i o n i s ma r ke d on
t h e t o ng ue b l a de a n d us e d a s a gui de f or t h e s e c o nd
e a r .
A d umb b e l l - s h a p e d i nc i s i o n i s ma d e on t h e me di a l
s ur f a c e o f t h e pi nna a nd t h e e l l i ps e o f s ki n a nd sof t
t i s s ue s i s r e mo v e d ( Fi g. 2 0 - 9 8 ) . I f t h e r e i s o nl y s l i gh t
o v e r pr o j e c t i o n o f t h e c o n c h a , c o nc h a l - ma s t o i d s u-
t ur e s of 4 - 0 wh i t e Et h i b o nd a r e pl a c e d i n a ma t t r e s s
pa t t e r n f r o m t h e ma s t o i d pe r i o s t e um t o t h e c o nc h a l
b o wl pe r i c h o ndr i um ( Fi g. 2 0 - 9 C) . Ext r a c o r r e c t i o n
c a n b e o b t a i ne d b y r e mo v i ng s ma l l di s ks o f c o nc h a l
b o wl c a r t i l a ge a t t h e c o nc h a l - ma s t o i d j unc t i o n ( Fi g.
2 0 - 9 D ) . A s h a r p No. 15 b l a de i s us e d t o s h a v e t h e
di s ks f r om t h e me di a l s ur f a c e o f t h e c o nc h a l bo wl ,
c a r e i s t a ke n t o l e a ve a l a ve r of c a r t i l a ge a nd per i -
c h o n d r i um i nt a c t o n t he l at er al s ur f a c e Ca ut i o n
s h o ul d b e e x e r c i s e d wh e n t h e c o nc h a l b o wl i s
b r o ug h t b a c k i nt o pr o pe r po s i t i o n b e c a us e t h e a nt e -
r i or c o nc h a l b o wl c a r t i l a ge c a n pr o j e c t i nt o t h e e xt e r -
na l a udi t o r y c a na l a nd na r r o w it. I f t h e c a na l i s ma d e
t o o na r r o w, t h i s e x c e s s c a r t i l a ge s h o ul d b e e x c i s e d.
T h e a nt h e l i c a l f ol d i s c o r r e c t e d t h r o ugh t h e s a me
i nc i s i o n. T h e p r o p o s e d a nt h e l i c a l f ol d i s o ut l i ne d o n
t h e l at er al s ur f a c e of t he pi nna wi t h a ma r ki ng pe n
( Fi g. 2 0 - 1 0 / 4 ) . T h e s ur g e o n o f t e n c a n ge t a c l e a r i d a
o f wh e r e t h e a nt h e l i c a l f ol d s h o ul d e xi s t by g e r l y
pr e s s i ng t h e h e l i c a l r i m t o wa r d t h e h e a d; t h e un-
p r o n o u n c e d a nt h e l i c a l f ol d wi l l a p p e a r o v e r t h e f or -
me r l y flat s ur f a c e of t h e s c a ph o i d r e gi o n. A 2 2 - ga t ge
ne e dl e i s pa s s e d t h r o ugh t h e l a t e r a l s ki n a n d car t i l c j ; e
a nd i nt o t h e po s t a ur i c ul a r i nc i s i o n. Me t h y l e n e bl i e
dy e i s t h e n a ppl i e d t o t h e ne e dl e tip a nd t h e nee< !a
i s wi t h dr a wn ( Fi g. 2 0 - 1 0 6 ) . T h i s ma r ks t h e me d a l
s ur f a c e of t h e c a r t i l a ge a nd s e r v e s as a gui de t t r
s ut ur e pl a c e me nt . T h e c a r t i l a ge a l o ng t h e me d l l
s ur f a c e of t h e p r o p o s e d a nt h e l i c a l f ol d i s s c o r e d wi h
a No . 15 bl a de t h r o ugh t h e c a r t i l a ge , but no t t h r o u^ h
t h e pe r i c h o ndr i um on t h e l a t e r a l s ur f a c e ( Fi g. 21 -
1 0C) . I f t h e i nc i s i o ns a r e t h r o ug h - a nd- t h r o ug h , e. i
una t t r a c t i ve a nt h e l i c a l f ol d r e s ul t s . Ne x t , t e mp o r a r /
4 - 0 s i l k h o r i zo nt a l ma t t r e s s s ut ur e s a r e pl a c e i
t h r o ugh t h e l a t e r a l s ur f a c e of t h e pi nna , t h r o ug h t h ' .
c a r t i l a ge , a nd b a c k out t h e l a t e r a l s ur f a c e , us i ng t h
ma r k s ma d e a s a gui de T e mp o r a r y s t a y s ut ur e s al l ov
t h e s ur g e o n t o " a dj us t " t h e a nt h e l i c a l f ol d t o obt a i r
s y mme t r y wi t h t h e o ppo s i t e e a r ( Fi g. 2 0 - 1 0 D ) . Wh i t '
4 - 0 Et h i b o nd h o r i zo nt a l ma t t r e s s s ut ur e s a r e t h e
pl a c e d o n t h e me di a l s ur f a c e o f t h e c a r t i l a ge t h r o ugh
t h e po s t a ur i c ul a r i nc i s i o n ( Fi g. 2 0 - 1 0 E) . Ca r e mus t
be t a ke n no t t o e xi t t h r o ugh t h e l a t e r a l s ur f a c e s ki n
Wh e n t h r e e t o f our s ut ur e s a r e i n pl a c e t h e t e mpo r a r y
s i l k s ut ur e s a r e r e mo v e d . An a nt h e l i x h a s n o w b e e n
f o r me d ( Fi g. 2 0 - 1 0 F ) .
Wi t h t he e a r n o w i n pr o pe r po s i t i o n, t h e a ppe a r -
a nc e o f t he c a uda h e l i x mus t b e a s s e s s e d ( Fi g. 2 0 -
11/ 1, B). Ex c e s s pr o j e c t i o n s h o ul d be r e mo v e d ( bv
c ut t i ng t h e Ca uda h e l i x ) o r mo r s c l i / e d ( bv s c o r i ng) s o
t ha t i t l i es f l a t t e r ( Fi g. 2 0 - 1 1 C, I ) ) . The s ki n on t he
l a t e r a l s ur f a c e of t h e pi nna i n t h e r e gi on of t h e c a uda
h e l i x s h o ul d a l s o b e un d e r mi n e d , s o t hat a f t e r r e s e c -
t i on of t he Cauda h e l i x t h e s ki n r e dr a pe s pr o pe r l y .
1 he po s t a ur i c ul a r i nc i s i o n i s c l o s e d wi t h 4- 0 Vi c r y l
a nd 6- 0 c h r o mi c or nv l o n s ut ur e s , a nd a bi l a t e r a l
ma s t o i d dr e s s i ng i s a ppl i e d. T h e dr e s s i ng c a n be l efl
on ( or o ne we e k l o pr e v e nt t r a uma t o t he e a r s . I f
ny l o n s ut ur e s h a v e b e e n us e d, t h e y c a n b e r e mo v e d
wh e n t h e dr e s s i ng i s r e mo v e d. T h e pa t i e nt mus t b e
c a ut i o ne d a ga i ns t e n g a g i n g i n c o nt a c t s po r t s unt i l s i x
we e k s a f t e r t he s ur ge r y .
SECTION V
Selected References
An s o n F3J a nd Do na l ds o n J A: Surgical Anatomy o f the Temporal Bone, 3 r d e d.
P h i l a de l ph i a , WB S a u n d e r s Co , 1 9 8 1 .
Ba i l e y BJ : Co c h l e a r pr o s t h e s i s i mpl a nt a t i o n: R e v i e w o f t h e i s s ue s ( e di t or i a l ) .
J A M A 2 5 1 : 3 2 8 2 , 1 9 8 4 .
Br a c k ma n D E: Neurological Surgery o f Ear and Skull Base. Ne w Yo r k, Ra v e n P r e s s ,
1 9 8 2 .
Br a nt - Za wa dz ki M a nd No r ma n D: Magnetic Resonance Imaging o f the Central
Nervous System. Ne w Yo r k, Ra v e n P r e s s , 1 9 8 5 .
Ch a k e r e s EW a nd L a Ma s t e r s DL: P a r a g a ng l i o ma s o f t h e t e mpo r a l b o ne : Hi gh
r e s o l ut i o n CT s t udi e s . Ra di o l o g y 2 5 0 : 7 4 9 - 7 5 3 , 1 9 8 4 .
Da ni e l s D L , Mi l l e n S J , Me y e r G A , e t al : MR de t e c t i o n o f t umo r i n t h e i nt e r na l
a udi t o r y c a na l . A J NR 8 : 2 4 9 - 2 5 2 , 1987.
Do y l e PJ : I ndi c a t i o ns f or a nd t e c h ni que o f e nda ur a l a nd po s t a ur i c ul a r i nc i s i o ns .
Ot o l a r y ng o l 6 : 2 6 2 - 2 6 6 , 1 9 7 7 .
Fa r r i o r J B: I nc i s i o ns i n t y mpa no pl a s t y : An a t o mi c c o ns i de r a t i o ns a nd i ndi c a t i o ns .
L a r y n g o s c o p e 9 3 : 7 5 - 8 6 , 1 9 8 3 .
Fi s c h U: Tympanoplasty and Stapedectomy. Ne w Yo r k, T h i e me - S t r a t t o n, 1 9 8 0.
F r i e dma nn 1: Pathology o f the Ear. Ox f o r d, Bl a c kwe l l S c i e nt i f i c P ub l i c a t i o ns , 1 9 7 4 ,
Ga c e k R R : Tr a ns e c t i o n o f t h e po s t e r i o r a mpul l a r y ne r v e f or t h e r e l i e f o f b e ni gn
pa r o x y s ma l po s i t i o na l ve r t i go . An n Ot o l Rh i no l La r y ngo l 8 3 : 5 9 6 - 6 0 5 , 1 9 7 4 .
Ga l l a gh e r J C: Histology o f the Human Temporal Bone. Ame r i c a n Re gi s t r y of
P a t h o l o gy . Wa s h i n g t o n D C, Ar me d F o r c e s I ns t i t ut e o f P a t h o l o g y , 1967.
Go o dh i l l V: S u d d e n de a f ne s s a n d r o und wi n d o w r upt ur e . L a r y n g o s c o p e
8 1 : 1 4 6 2 - 1 4 7 4 , 1 9 7 1 .
Gr i f f i n C, De La P a z R, a nd En z ma n n D: MR a n d CT c o r r e l a t i o n o f c h o l e s t e r o l
c y s t s o f pe t r o us b o ne . A J NR 8 : 8 2 5 - 8 2 9 , 1987.
Ho u s e WF : S ur gi c a l c o ns i de r a t i o ns i n c o c h l e a r i mpl a nt a t i o n. An n Ot o l Rh i no l
La r y ngo l 9 1 ( S u p p l ) : 1 5 - 2 0, 1 9 8 2 .
Ho u s e WF a nd Lue t j e CM: Acoustic Tumors, Vo l s I a nd II. Ba l t i mo r e , Uni v e r s i t y
P a r k P r e s s , 1 9 7 9 .
| a n s e n C: P o s t e r i o r t y mp a n o t o my : Ex pe r i e nc e a nd s ur gi c a l de t a i l s . Ot o l a r y ngo l
Cl i n No r t h Am 5 : 7 9 - 9 6 , 1 9 7 2 .
La t a c k J T , Ka r t us h J M, Ke mi n k J L , e t al : Ep i d e r mo i d o ma s o f t h e c e r e b e l l o -
po nt i ne a ngl e a nd t e mpo r a l b o ne : CT a nd MR a s pe c t s . Ra di o l o gy 1 5 7 : 3 6 1 -
3 6 6 , 1985.
Li m DJ : Hu ma n t y mpa ni c me mb r a n e . Ac t a Ot o l a r y ngo l 7 0 : 1 7 6 - 1 8 6 , 1970.
Li m DJ : F unc t i o na l mo r p h o l o g y o f t h e l i ni ng me mb r a n e o f t h e mi ddl e e a r a nd
e us t a c h i a n t ube . An o v e r v i e w. An n Ot o l Rh i no l La r y ngo l 8 3 ( S up p l ) : 5 - 2 6 ,
1 9 7 4 .
Ma r que t J F E ( e d) : Surgery and Pathology o f the Middle Ear. Bo s t o n, Ma r t i nus
Ni j h o f f , 1 9 8 5 .
Na g e r GT a nd Na g e r M: Ar t e r i e s o f t h e h u ma n mi ddl e e a r , wi t h pa r t i c ul a r
r e ga r d t o t h e b l o o d s uppl i e s o f t h e a udi t o r y o s s i c l e s . An n Ot o l Rh i no l
La r y ngo l 6 2 : 9 2 3 - 9 4 9 , 1 9 5 3 .
Na u ma n n HH: Head and Neck Surgery. Vol 3: Ear. P h i l a de l ph i a , WB S a u n d e r s
Co , 1 9 8 2 .
Na u n t o n RF : T y mp a n o s t o my t ub e s : T h e c o ns e r v a t i v e a ppr o a c h . An n Ot o l
Rh i no l La r y ngo l 9 0 : 5 2 9 - 5 3 2 , 1 9 8 1 .
P a pa r e l l a MM a nd S h u mr i c k DA: Otolaryngology ( Vo l s . 1 a nd 3 ) . P h i l a de l ph i a ,
WB S a u n d e r s Co , 1 9 8 8 .
P o r t ma nn M: The Ear and Temporal Bone. Ne w Yo r k, Ma s s o n , 1 9 7 9 .
362 S e l e c t e d Re f e r e nc e s
P r o c e e di ngs o f t h e s e c o nd i nt e r na t i o na l s y mp o s i u m a n d wo r k s h o p s o n s ur g e r y
o l ( h e i nne r e a r ( S n n wma s s , As pe n, Co l o r a do ) : Tar t 2. Am J Ot o l 8 : 2 7 1 -
3 6 8 , 1987.
I ' r o c t o r B: T h e d e v e l o p me n t o f t h e mi ddl e e a r s pa c e s a nd t h e i r s ur gi c a l
s i gni f i c a nc e . J La r y ngo l Ot o l 7 8 : 6 3 1 - 6 4 8 , 1 9 6 4 .
P r o c t o r B a nd Na g e r CT : T h e facial c a na l : No r ma l a n a t o my , v a r i a t i o ns a nd
a no ma l i e s . T r a n s Am Ot o l S o c 7 0: 4 9 , 1 9 8 2 .
S c h u k n e c h t HP: Stapedectomy. Bo s t o n, Li t t l e , Br o wn & Co , 1 9 7 1 .
S c h t t kne c h t HF: Pathology o f the Ear. Ca mb r i d g e , Ha r v a r d Uni v e r s i t y P r e s s ,
1974.
S c h u k n e c h t 14F a nd Gul y a J A: Anatomy o f the Temporal Bone with Surgical
Implications. P h i l a de l ph i a , Le a a nd Fe bi ge r , 1 9 8 6 .
S h a mb a u g h Cf i J r a nd Gl a s s c o c k ME III: Surgery o f the Ear, 3r d e d. P h i l a de l ph i a ,
WB S a u n d e r s Co , 1980.
She a ' D, Ch o l e R, a nd P a pa r e l l a MM: T h e e n d o l y mp h a t i c s a c : Ana t o mi c a l
c o ns i de r a t i o ns . L a r y n g o s c o p e 8 9 : 8 8 - 9 4 , 1 9 7 9 .
S ur gi c a l i mpl a nt a t i o n t e c h ni que f or Xo me d Audi a nt Bo n e Co n d u c t o r ( b a s e d o n
t h e t e c h ni que o f J . Ho u g h ) ( pub. no . 5 0 - 1 5 0 0 ) . J a c ks o nv i l l e , Xo me d I nc ,
1986.
S wa r t z J D: Imaging o f the Temporal Bone: A Text-Atlas. Ne w Yo r k , T h i e me , 1 9 8 6 .
Wo l f f D, Be l l uc c i RJ , a nd Eggs t o n AA: Surgical and Microscopic Anatomy o f the
Temporal Bone. Ne w Yo r k , Ha f ne r P ub l i s h i ng Co , 1 9 7 1 .
Index
Page numbers in italic* indicate illustrations
A
Abscess(es), intracranial, complicating
suppurative otitis media, 194, 196
periauricular, complicating suppurative otitis
media, 797, 198
Acoustic meatus, external, 5, 6
Acoustic nerve, 21
Acoustic neuromas, translabyrinthine approach
for, 331-338. Sec a/so Translabyrinthine
approach, for acoustic neuromas
Acoustic schwannoma, intracanalicular CT and
MR imaging of, 31
Adhesions/tissue, for ossicular chain grafting,
223
Adhesive otitis, tympanoplasty for, 175, 177,
178-180
Aeration lubes, transmeatal permanent, for
otitis media, 171-173
Allograft, for total perforation, 233, 234
Ampullae, 20
Amputation of pinna, total, plastic surgery for,
345-347, 348
Anatomy, pertinent, 3-22
Anesthesia, for otologic procedures, 10 2
Annular ligament, 12
Antibiotics, prophylactic, for otologic
procedures, 10 2
Artery(ies), of external ear, 7, 8
of inner ear, 21
of middle ear, 14, 75
Atelectatic tympanic membrane,
histopathologv of, 20 3
tympanoplasty for, 175, 177, 178-179
Atherosclerosis screening, vascular ultrasounc
for, 28, 35
Atresia, congenital. Sec Congenital atresia.
Auditory canal, internal, middle fossa
approach to, 93, 95-96, 97
translabyrinthine approach to, 87, 89, 90 , 91
Auditory nerve, 21
Auditory tube, 12, 14
Auricle, anatomy of, 3- 6
plastic surgery of, 339-358. See also Plastic
surgery of pinna.
Auricular artery, posterior, 14
stylomastoid branch of, 8
Auricular branch, of vagus nerve, 8
Auricular nerve, great, 8
Auricular rami, 8
Auriculotemporal branch, of trigeminal nerve,
8
B
Basilar membrane, of osseous labyrinth, 19
Biopsv, of externa] auditory canal tumors, 153,
154
Bleeding, complicating total stapedectomy with
prosthesis, 257
Bleeding (Continued)
jugular bulb, complicating translabyrinthine
approach for acoustic neuromas, 337
sinus, complicating translabyrinthine
approach for acoustic neuromas, 337
Block method, for temporal bone removal, 39,
40
Blood vessels, of external ear, 7, 8
Bone, cortical, for ossicular chain grafting, 222
skull transcochlear approach to, 90 , 92, 93,
94
temporal. See Temporal bone.
Bone conduction hearing devices, surgical
approach for, 281-285. See also Hearing
devices, bone conduction, surgical
approach for.
Bone plug method, for temporal bone removal,
40-41, 43
Bundle of Oort, 22
C
Canalplasty, 59, 6 2, 6 3, 149-151, 152
in exploratory tympanotomy, 127, 129, 130
Caroticotympanic artery, 14
Carotid artery, cervical, atherosclerosis of,
vascular ultrasound screening for, 28, 35
external, posterior auricular branch of, 8
Carotid wall, of middle ear, 10
Cartilage, for ossicular chain grafting, 222
Cartilage tympanoplasty, for atrophic tympanic
membrane, 173-175, 176
Ceramics, for ossicular chain grafting, 222
Cerebellopontine angle, retrolabyrinthine
approach to, 82, 85, 87, 88
with vestibular nerve sectioning, for
incapacitating peripheral vertigo, 30 7, 30 9,
370 -317
Cerebrospinal fluid leak, complicating total
stapedectomy with prosthesis, 26 1
Chemodectoma, of jugular foramen, MR
imaging of, 32
Cholesteatoma, CT imaging of, 30
Cholesterol granuloma, of medial petrous
apex, MR imaging of, 33
Chorda tympanic branch, of facial nerve, 16
Cleft ear lobe, plastic surgery for, 339-341, 342
Closed-cavity tympanomastoidectomy, for
otitis media, 181-183, 184
meatoplasty in, 140 , 747
Coalescent mastoiditis, complicating
suppurative otitis media, 192
Cochlea, 19
Cochlear aqueduct, 19
Cochlear artery, 21
Cochlear division, of vestibulocochlear nerve,
22
Cochlear duct, 20
Cochlear fossa, of middle ear, 10
Cochlear implant(s), 75, 82, 83-84
components of, 286
facial recess approach to, 54, 55-58, 59
surgical approaches for, 286 -296
3 6 3
364 I nde x
Cochlear implant(s) (Continued)
surgical approaches for, mastuidotomy/
tympanotomy as 2S7
Gochlcariform prna^s, in middle e 1U
22o"'2fi
r

f
'
f

r t y m p a n i c m
^ b r a n c .
Computed tomography (CT) imaging, of
temporal bone, 28, 29-31, 34
Congenital atresia, 159-16 3
histopathology of, 16 3
surgical technique for, 159-16 3
Congenital malformations, of pinna, plastic
surgery for, 353- 358
Consent, patient, preoperative, 10 1-10 2
Cortical bone, for ossicular chain grafting, 222
Cortical mastoidectomy, for otitis media, 181
Cristae, 20
Cupula, 20
Descending artery, H
Drainage, petrous, 71, 72
Drills, in operating room, 10 7
Ductus reuniens, 20
Dura mater exposure, complicating simple
mastoidectomy, 135, 137
Earlobe, cleft, plastic surgery for, 339-341, 342
Elliptical recess, of osseous labyrinth, 18
Endaural approach, to external ear canal and
middle car, 130 -132
Endolymphatic duct, 20
Endolymphatic sac, 20
procedures on, for incapacitating peripheral
vertigo, 297-298, 299-301
surgery on, 47, 49, 50-51
Endosteum, of osseous labyrinth, 19
Epitympanic cells, 17
Epitympanic recess, of tympanic cavity, 9
Epitympanum, 24
Equipment, and procedures in operating room,
10 2-111
for temporal bone removal, 42, 43
Eustachian tube, 12, 14
Exostosis, canalplasty for, 149, 750 , 151
"Exteriorized" mastoid cavity, for otitis media
191
External acoustic meatus, 5, 6
External ear, anatomy of, 3-8
auricle of, 3 - 6
bony features and relationships of, 3
canal of, approach to, endaural, 130 -132
mastoidotomv as, 137-138
meatoplasty as, 138-140 , 141
postauricular, 132-133, 134
posterior tympanotomy as, 137
simple mastoidectomy as, 133, 135-137
Thiersch graft in, 140 -143
transcanal, 121-127, 128. Sir ahn
Transcanal approach, to external ear
canal and middle ear.
histopathology of, 144-145
procedure on, 149-158
stenotic, canalplasty for, 151
tumors of, 151, 153, 754-155, 156 , 157-15$
innervation of, 8, 9
External ear (Continued)
vascular supply of, 7, 8
External otitis, intractable, canalplasty for, 151,
112
Facial canal, 17
facial nerve, avulsion of, complicating
translabyrinthine approach for acoustic
-neuromas, 337
chorda tympanic branch of, 16
decompression of, transmastoid, 58, 6 0 -6 7
histopathology of, 324
in temporal bone, 17
paralysis of, complicating suppurative otitis
media, 192, 194
surgery on, infratemporal, 315-324
myringotomy as, 315
middle cranial fossa approach to, 320 -324
iranscanal approach to, 317, 379, 320
transmastoid approach to, 315-317, 318
trauma to, complicating simple
mastoidectomy, 135
Facial recess approach, to cochlear implant, 54,
55-57. 58, 59
to posterior tympanotomy, 49, 52- 53, 54
Fallopian canal, 17
Fissula ante fenestram, 19
Fistula, perilymphatic, exploratory
tympanotomy for, 210 -213
Footplate, floating, complicating total
stapedectomy with prosthesis, 260, 26 1
Foramen of Huschke, 3
Foramen singulare, 21
Foraminifcrous spiral tract, 2]
Foreign body reaction, in operating room
10 4-10 5
Fossa of incus, 10
Fossub fenestrae cochleae, 10
Fossula fenestrae vestibuli, 10
Fossula post fenestram, 19
Fragments, depressed, complicating total
stapedectomy with prosthesis, 26 0 . 26 1
Gelfoani, for ossicular chain grafting, 222-227
Geniculate ganglion, 19
Glomus jugulare tumors, infralahyrinthine,
infratemporal approach to, 327-331
Glomus tympanicum tumors, 325-327
Glossopharyngeal nerve, tympanic branch of,
14
Clues, for ossicular chain grafting, 223
Graft(s), harvesting of, for total stapedectomy
with prosthesis, 249, 252. 253
Thiersch, 140 -141
tympanoplasty, classification of, 219
underlay, of tympanic membrane, 6 2, 6 3, 64
Grafting, of ossicular chain, 220 , 222-223
of tympanic membrane, 220 , 221
Granulation tissue, debridement of, from
mastoid cavity, for Thiersch graft, 141-143
Granuloma, cholesterol, of medial petrous
apex, MR imaging of, 3.3
Hair
l ion
cells, of spiral organ, 21
ulus. 19
I nde x 36 5
Hearing devices, bone conduction, surgical
approach for, 281-285
aims of, 281
complications of, 285
procedure for, 281, 283-284. 285
Helicotrema, of osseous labyrinth, 19
Helix, spine and tail of, 4
Hematoma of pinna, plastic surgery for, 342,
343-344
Histology, 23-27
Hypotympanic cells, 17
Implant, cochlear, 75, 82, 83-84
facial recess approach to, 54, 55-5S, 59
IncudomaUeal joint, 12
Incus, anatomy of, 12, 13
dislocation of, complicating simple
mastoidectomy, 137
complicating total stapedectomy with
prosthesis, 257, 259
lesions of, tympanoplasty-ossiculoplasty for,
235, 239. 241
Incustapedial joint, 12
Informed consent, preoperative, 10 1-10 2
Infralabyrinthine, infratemporal approach to
glomus jugulare tumors of, 327-331
Inner ear, anatomy of, 17-22
nerves of, 21-22
sensorj' receptors of, 20 -2]
tumors of, 331-338
vascular supply of, 21
Innervation, of external ear, 8, 9
Instruments, for operating room, 10 5, 10 7, 10 9,
770 -777
for temporal bone removal, 42, 43
Intact bridge mastoidectomy, 6 3, 6 7, 68
Intact-bridge tvmpanomastoidectomy (IBM),
for otitis media, 183, 185, 786 -190
Intracranial abscess, complicating suppurative
otitis media, 194, 796
Intratemporal facial nerve surgery, 315-324
myringotomy as, 315
lontophoretic anesthesia, 10 2
Isthmus, 4
Iter chordae tympani posterior, 10
i
Jacobson's nerve, 14
Jugular bulb bleeding, complicating
translabyrinthine approach to acoustic
neuromas, 337
Jugular foramen, chemodectoma of, MR
imaging of, 32
Jugular wall, of middle ear, 9-10
K
Keloids, plastic surgery for, 341, 343
L
Labyrinth, of inner ear, 18
membranous, 19-20
osseous. 18-19
Labyrinthectomy, 71, 73, 74- 75
for incapacitating peripheral vertigo, 30 2,
305-306, 30 7, 308
transcanal, 82, 85. 86
Labyrinthine artery, 21
Labyrinthine vein, 21
Labyrinthine wall, of middle ear, 10
Labyrinthitis, complicating suppurative otitis
media, 194
Laceration of pinna. with tissue loss, plastic
surgery for, 345
without tissue loss, plastic surgery for, 344-
345
Laserfs), applications of, in middle ear,
276 -278
for neurotology, 278-280
for ossicular problems, 276 -278
for otologic surgery, 272
for stapedotomy, 273-276
Lidocaine, for anesthesia, 10 2
Ligament(s), annular, 12
auricle, 6
mallear, 12
Limbus, 19
Lop ears, plastic surgery for, 353, 354, 358
M
Maculae, 20
Magnetic resonance (MR) imaging, of temporal
bone, 28, 31-34
Malleal stria, of tympanic membrane, 6
Mallear ligaments, 12
Mallear prominence, of tympanic membrane,
6 -7
Malleus, anatomy of, 12, 73
lesions of, tympanoplasty-ossiculoplasty for,
235, 236-238
Malleus-to-ova window prosthesis, for stapes
fixation, 26 3, 26 6 , 26 7
Mastoid air cells, 17
Mastoid cavitv, exteriorized, for otitis media,
191
granulation tissue from, debridement of, for
Thiersch grafts, 141-143
obliteration procedures for, for otitis media,
191-192, 193
skin graft of, 142, 143
Mastoid procedures, for otitis media, 177, 181,
185, 191
Mastoid wall, of middle ear, 10
Mastoidectomy, cortical, for otitis media, 181
intact bridge, 6 3, 6 7, 68
radical, 6 3, 6 7, 70 , 71
modified, 6 3, 6 7, 6 9
for otitis media, 185, 191
simple, 44 -47, 48
as surgical approach, 133. 135-137
Mastoidectomy-tympanotomy approach, to
cochlear Implant, 75, 82, 83-84
Mastoiditis, coalescent, complicating
suppurative otitis media, 192
Mastoidotomy, 137-138
Mastoidotomy/tympanotomy, for cochlear
implants, 287, 292-296
Maxillary artery, branches of, 8
Meatoplasty, 138
in closed-cavity tympano-mastoldectomy,
140 , 141
in open-cavity tympano-mastoidectomy,
138-140
Membranous labyrinth, 19-20
individual components of, 20
Membranous semicircular canals, 20
366 I nde x
Membranous wall, of middle ear, 9
Meningitis, complicating suppurative otitis
media, 194
Meso tympanum, 27
Microscope, operating, 10 5, 10 7, 70 S, 109
Middle cranial fossa approach, to
infratemporal facial nerve surgerv, 320 -324
Middle ear, anatomy of, 8-17
approach to, endaural, 130 -132
mastoidotomy as, 137-138
meatoplasty as, 138
closed-cavity tympano-mastoidcctornv
as, 140 , 141
open-cavitv tympano-mastoidcctornv as,
138- 140 '
postauricular, 132-133, 134
posterior tympanotomy as, 137
simple mastoidectomy in, 133, 135-137
Thiersch graft in, 140 -143
transcanal, 121-127, 128. Sir also
Transcanal approach, to external ear
canal and middle car.
auditory tube of, 12-14
dissection of, 75, 76-81
histopathology of, 144-145
laser applications in, 276 -278
morphology of, 8- 10 , 11
mucosal lining of, 14
nerves of, 14-16
ossicles of, 10 , 12, 13
tumors of, 325-331
glomus jugulare, 327-331
glomus tympanicum as, 325-327
vascular elements of, 14, 15
Middle fossa approach, to internal auditory
canal, 93, 95-96, 97
Modiolus, 19
Mondini's deformity, CI" imaging of, 29
Mucosal lining, of middle ear, 14
Muscle(s), of auricle, 6
Stapedius, 12
tensor tympani. 12
Myringoplasty, tvpe I l\ mp.iriopl.iMv and,
223-213
allograft in, lor total perloration. 233, 234
approach to, 223, 225. 226
for small central perforation, 225. 227-22$
overlay technique of, for central
perforation. 22^. 22
l
K 230
underlay graft in. Un large .interim
perforation, 230 , 232. 231
for posterior perforation in atrophic
membrane. 231). 231
Myringotomy and tubes, for otitis- media,
16 4-171
aim of, 16 4
complications of, 170 -171
incisions for, 16 5, 16 6 -16 7, 16 8
indications for, 16 4-16 5
instruments for, 16 5
tubes in, 16 8-170
for intratempora! facial nerve surgery, 315
N
Neoplasms of pinna, plastic surgery for, 347
349-353
Nerve(s), facial, decompression of,
transmastoid, 58, 60-61
of externa] ear, 8, 9
Of inner ear, 21-22
of middle early, 14, 16
Neurectomy, singular, for incapacitating
peripheral vertigo, 30 2, 30 4
lympanic, exploratory tympanotomy for,
211, 213, 214
Neuromas, acoustic, translabyrinthine
approach lor, 331 -338. See also
Translabyrinthine approach for acoustic
neuromas.
Neurotology, lasers for, 278-280
O
Occipital artery, 14
Open-cavity tympano-mastoidectomy,
meatoplasty in, 138-140
Operating microscope. 10 5, 10 7, 10 8. 109
Operating room, 10 1-111. Sec a I fin Surgery,
equipment and procedures in, 10 2-111
foreign body reaction in, 10 4-10 5
instruments in, 10 5, 10 7, U0-1U
positioning of surgical team in, 10 5, /0 6
record of operation in, 10 9, 111, 111-120
skin preparation in, 10 3-10 4
surgical time in, \ \ \
Operating room cards, for instruments and
materials, 10 9
Organ of Corti, 20
Osseous labyrinth, 18-19
Osseous spiral lamina. 19
Ossicles, anatomy of, 10 , 12, 13
for ossicular chain grafting, 222
laser applications in, 276 -278
problems of, combined, tympanoplasty-
ossiculoplasty for, 240 , 241, 243
Ossiculoplasty, 6 2, 6 3, 65-66
in tympanoplasty, 233, 235-243. S,v also
Tympanoplasty-ossiculoplasty.
Otitis, external, intractable, canalplasty for,
m , 152
Otitis media. IM -2(N
cartilage Ivmpanopla-l\ loi atropine
IVIUCMOIC membrane lor. 173 175, J7c
exleriuri/ed mastoid civilv lor, I9|
lnsiop.uhology oh JW-20
mastoid oblitration procedure lor 191-142
inaMoid procedure- in. 177. 1st. IS".. I'll
m.iMoidei limn (>>i
u.rtie.il | K1
radical. I'M
modilied. 1X5, I'M
mucoid, histopathology of. 199
myringotomy and tubes for. 16 4-171. Sec al<o
Myringotomy and tubes, for otitis media
suppurative. Sec Suppurative otitis media.
Iransmeatal permanent aeration tubes for,
171-173
tympanomastoid procedures in, 177
181-185; 186-190
tympanomastoidectomy for, closed-cavity,
181-183, 184
intact-bridge, 183, 185, 1S6 -790
tympanoplasty for atelectatic tympanic
membrane for, 175, 177, 17S-180
Otolithic membrane, 20
Otoliths, 20
Otologic evaluation, preoperative, 10 1
Otoplasty, 353-358
Oval window, 19
narrow, complicating total stapedectomy
with prosthesis, 257, 259, 26 1
I nde x 36 7
P
Pain, complicating total stapedectomy with
prosthesis, 257
Paraganglioma, MR imaging of, 32
Paralysis, inlratemporal facial nerve, surgery
for, 315-324
myringotomy as, 315
Pars fiaccida, 7
Pars tensa, 7
Patient consent, preoperative, 10 1-10 2
Periauricular abscess, complicating suppurative
otitis media, 197, 198
Perilymphatic fistula, exploratory
tympanotomy for, 210 -213
Periosteum, of osseous labyrinth, 19
Peripheral vertigo, incapacitating, surgery for,
297-314
Petrosal artery, superficial, 14
Petrosal nerve, lesser, 16
Petrositis, complicating suppurative otitis
media, 194, 195
Petrotympanic sutures, 3
Petrous apex, cells of, 17
medial, cholesterol granuloma, MR imaging
of, 33
Petrous drainage, 71, 72
Petrous portion, of external ear, 3
Phalangeal cells, 20
Pharyngotympanic tube, 12, 14
Plastic surgery of pinna, 339-358
for amputation of pinna, total, 345-347, 348
for cleft car lobe, 339-341, 342
for congenital malformations, 353-358
for hematoma, 342, 343-344
for keloids, 341, 343
for laceration
with tissue loss, 345
without tissue loss, 344-345
for neoplasms, 347, 349-353
Plastics, for ossicular chain grafting. 222
Plastipore. for ossicular chain grafting. 222
Pneumati/ation, of temporal bone, lh-17
Portmann technique, for Iransmeatal
permanent aeration lube insertion, 171,
172
I'osljuncular approach, to external ear canal
and middle ear, 132-133, 134
Preoperative otologic evaluation, 101
Prominence, of facial canal, Ul
ut lateral semicircular canal, 10
Prominent ears, plastic surgery for, 353,
355-357. 358
Promontory of middle ear, 8
prominent, complicating total stapedectomy
with prosthesis, 257, 259
Prosthesis, malleus-to-oval window, for stapes
fixation, 26 3, 266, 26 7
partial ossicular replacement, for malleus
lesion, 235
total ossicular replacement, for combined
ossicular problems, 240, 241-243
total stapedectomy with, 249-26 1. Sec also
Stapedectomy, total, with prosthesis.
Pyramidal eminence, of middle ear, 10
R
Radical mastoidectomy, modified, 6 3, 6 7, 6 9
Record of operation, 10 9, 111, 711-120
Rctrolabyrinthine approach, to
cerebellopontine angle, 82, 85, 87, 88
and vestibular nerve sectioning, for
incapacitating peripheral vertigo, 30 7,
30 9, 310 -311
Round window, 19
Round window niche, of middle ear, 10
Saccular duct, 20
Saccule, 20
procedures on, for incapacitating peripheral
vertigo, 30 2, 30 3
Scala tympani, 19
Scala vestibuli, 19
Schuknecht's method, of temporal bone
removal, 39, 40-41, 43
Schwannoma, acoustic, intracanalicular CT and
MR imaging of, 37
seventh nerve, MR imaging of, 34
Scutum, 9
Semicanal, for tensor tympani muscle, 10
Semicircular canals, drilling of, complicating
simple mastoidectomy, 137
membranous, 20
of osseous labyrinth, 18-19
Sensory receptors, of inner ear, 20 -21
Sigmoid sinus, damage to, complicating simple
mastoidectomy, 137
thrombophlebitis of, complicating
suppurative otitis media, 194, 196 -197, 198
Silastic for ossicular chain grafting, 222
Sinus, bleeding in, complicating
translabyrinthine approach for acoustic
neuromas, 337
posterior, of middle ear, 10
Skin grafts, for tympanic membrane, 220 , 221
preparation of, in operating room, 10 3-10 4
thin, harvesting, for Thiersch grafts, 142, 143
Skull bone, transcochlear approach to, 90 , 92,
93. 94
Spherical recess, of osseous labyrinth, 18
Spine of helix, 4
Spiral ganglion, 22
Spiral ligament, of osseous labyrinth, 19
Spiral organ, 20
Spiral sulcus, internal, of osseous labyrinth, 19
Squamolympanic sutures, 3
Squamous portion, of external ear, 3
Stapedectomy, harvesting, grafts in, 249, 252,
253
making prosthesis in, 253, 254-255
problems and variations during, 257,
259-260, 26 1
procedure in, 253, 256 , 257, 258
total, with prosthesis, 249-26 1
Stapedius muscle, 12
Stapedotomy, 26 1
laser. 273-276
Stapes, anatomy of, 12, 73
fixation of, in obliterative otosclerosis, 26 1,
262
interposition procedure for, 26 1, 26 3, 26 4
malleus-to-oval window prosthesis for,
26 3, 26 6 , 26 7
stapedotomy for, 26 1
surgery for, 247-271
total stapedectomy with prosthesis for,
249-26 1. Sec also Stapedectomy, total,
with prosthesis,
histopathology of, 26 8-271
lesions of, tympanoplasty-ossiculoplasty for,
240, 241
368 I nde x
Stapes footplate, 25
Stapes interposition, 26 1, 26 3, 26 4
Statoacoustic nerve, 21
Statoconic membrane, 20
Stenotic canal, canalplasty for, 15]
Stria vascularis, 20
Stylomastoid branch, of posterior auricular
artery, 8, 14
Subiculum, of middle ear, 10
Suction, in operating room, 10 7, 10 9
Suppurative otitis media, complications of
coalescent mastoiditis as, 192
facial nerve paralysis as, 192, 194
intracranial abscess as, 194, 196
labyrinthitis as, 194
meningitis as, 194
periauricular abscess as, 197, 198
petrositis as, 194, 195
sigmoid sinus thrombophlebitis as, 194,
796 -197, 198
surgery for, 192, 194-198
Suprameatal spine, 3
Suprameatal triangle, 3
Surgery, anesthesia for, 10 2
antibiotics for, 10 2
evaluation for, 101
patient consent for, 10 1-10 2
record of, 10 9, 111, 717-720
Surgical team, positioning of, in operating
room, 10 5, 10 6
Surgical time, in operating room, 11]
T
Tail of helix, 4
Tectorial membrane, 20
Teflon, for ossicular chain grafting, 222
Tegmen tympani, 9
Tegmental wall, of middle ear, 9
Temporal bone, dissection of, 37-97
procedures for, 44-97
canalplasty as, 59, 6 2, 6 3
cochlear implants as, 54, 55- 55, 59, 75.
82, 83-S4
endolymphatic sac surgery as, 47, 49,
50 -57
facial recess approach to posterior
tympanotomy as. 49, 52-53, >-l
intact bridge mastoidectomy as, 6 3, 6 7,
68
labyrinthectomy as, 71, 73 . 74- 75
middle ear dissection as. 75, 76 -81
middle fossa approach to internal
auditor,' canal as, 93, 95-96, 97
ossiculoplasty as, 6 2, 6 3, 65-66
petrous drainage as, 71, 72
radical mastoidectomy as, 6 3, 6 7, 70, 71
modified, 6 3, 6 7, 69
retrolabyrinthine approach to
cerebellopontine angle as, 82, 85, 87,
88
Simple mastoidectomy as, 44-47, 48
transcanal'labyrinthectomy as, 82, 85, 86
transcochlear approach to skull bone as,
90 , 92, 93, 94
translabyrinthine approach to internal
auditory canal as. 87, 89, 90 , 91
transmastoid facial nerve decompression
as, 59, 6 0 -6 7
underlay graft of tympanic membrane
as, 6 2, 6 3, 6 4
facial nerve in, 17
Temporal bone (Continual)
histology of, 23 r 27
imaging of
by computed tomography, 28, 29-31, 34
by magnetic resonance, 28, 37-34
high resolution, 28-35
paraganglioma of, MR imaging of, 32
pneumatizaHon of, 16 -17
removal of, 39- 43
resection of, subtotal, 153, 755, 156
total, 136 , 157-75S
Tensor tympanic muscle, 12
Terminal incisure, 4
Thiersch graft, 140 -143
debridement of granulation tissue from
mastoid cavity for, 141-143
harvesting thin skin for, 742, 143
of mastoid cavity, 142, 143
Thrombophlebitis, sigmoid sinus, complicating
suppurative otitis media, 194, 196-197, 198
Tissue adhesions, for ossicular chain grafting,
223
Transcanal approach, to external ear canal and
middle car, 121-127, 128
closure in, 125 I
evaluation of flaps in, 123, 124, 125
exposure of middle ear in, 125, 726
highlights of, 121
incisions in. 123, 124
injection of local anesthetic in, 123, 724
inspection and cleansing in, 121, 123
packing in, 127, 728
pitfalls in, 121
revisions in, 125, 127
to intratemporal facial nerve surgery, 317,
379, 320
to labyrinthectomy, for incapacitating
peripheral vertigo, 30 2, 30 6
Transcanal labyrinthectomy, 82, 85. 86
Transcochlear approach, to skull bone, 90 , 92,
93, 94
Translabyrinthine approach, to acoustic
neuromas, 331-338
aim of, 331
highlights of, 331
intraoperative complications or problems
with, 337-338
pitfalls of, 331
procedure for, 331-337
to internal auditory canal, 87, 89, 90 , 9?
Transmastoid approach, to infratemporal facial
nerve surgery, 315-317, 378
to labyrinthectomy, for incapacitating
peripheral vertigo, 30 7, 30 8
Transmastoid labyrinthine dissection, 71, 73,
74-75
Transmeatal permanent aeration tubes, for
otitis media, 171-173
Transmoid facial nerve decompression, 59,
6 0 -6 1
Transverse crest of fundus, 21
Trigeminal nerve, auriculotemporal branch of,
8
Tumor(s), external auditory canal, 151, 153,
754-155, 156 . 757-758'
inner ear, 331-338
middle ear, 325-331
glomus tympanicum, 325-327
glomus jugulare, 327-331
of pinna, total, plastic surgerv for, 347,
349-353
Tympanic artery. 14