CANALPLASTY

TIMOTHY

T.K. JUNG,

MD,

PhD

Canalplasty is a procedure to restore the normal width and contour of the external auditory canal. This procedure is
often used as part of tympanoplasty. Whenever the entire tympanic membrane and anulus cannot be visualized intraoperatively, canalplasty is indicated so that the ample canal and anulus can be seen circumferentially and completely.
It can also be used for the removal of large obstructing exostosis, surgical treatment of intractable obliterative external
otitis media, correction of a stenotic and tortuous canal from any cause, and excision of tumors in the canal. Surgical
steps include transcanal, endaural, or postauricular incision, elevation of canal skin flap, widening of the bony canal,
placing back the canal skin flaps or skin graft, and packing and closure. Possible complications of canalplasty include
exposure of the temporomandibular joint, opening into the mastoid air cells, damaging the tympanic membrane, ossicles, and skin flaps, or infection such as perichondritis.

INDICATIONS
Canalplasty is a procedure to restore the normal width and
contour of the external auditory canal. It includes replacing
diseased canal skin with healthy skin.
This procedure is frequently used as a part of routine
tympanoplasty.I Adequate tympanoplasty cannot be performed unless the entire tympanic membrane and anulus
can be seen at the time of surgery. Whenever an obstruction
such as a bony overhang blocks the view of the entire
tympanic membrane and anu]us at the time of tympanoplasty, canalplasty is indicated so that the full circumferential anulus and tympanic membrane can be seen. This
helps not only intraoperatively, but also in postoperative
care and in follow-up examinations.
Canalplasty is also indicated when the external auditory
canal is blocked or stenotic from any cause. For example,
canalplasty can be performed for the removal of a large
obstructing exostosis, surgical treatment of intractable
obliterative external otitis, reconstruction of a stenotic and
tortuous canal including congenital stenosis, tumors of the
canal, and keratosis obturans.

WORK-UP AND PREPARATION OF THE

PATIENT
High-resolution computerized tomography (CT) of the
temporal bone is not mandatory before all canalplasties,
but should be performed for cases with tumors, congenital
stenosis, and any unusual bony or soft tissue obstructive
lesions. In the presence of tumors, magnetic resonance
imaging (MRI) is helpful to evaluate the extent and
location of the tumor.
As in any other otologic procedure, an audiogram of the
patient should be obtained before the procedure. For the
patient with intractable obliterative external otitis, underly-

From the Division of Otolaryngology-Head and Neck Surgery, Loma

Linda UniversitySchool of Medicine, Loma Linda, CA.
Address reprint requests to Timothy T.K. Jung, MD, PhD, 11790 Pecan
Way, Loma Linda, CA 92354.
Copyright 1996 by W.B. Saunders Company
1043-1810/96/0701-0012505.00/0

ing causes such as diabetes mellitus, allergies, and autoimmune disease should be ruled out.

OPERATIVE TECHNIQUE
The procedure is usually performed with general anesthesia, although it can be done with local anesthesia also. In
either case, local injection of 1% lidocaine with 1:100,000
epinephrine is injected into the four quadrants of the
external auditory canal and postauricular skin before the
surgical prep is applied.
AS A PART OF TYMPANOPLASTY

The best time for the canalplasty during a tympanoplasty or tympanomastoidectomy is right after elevating
posterior canal skin for the posterior bony overhang and
before grafting tympanic membrane for the anterior bony
overhang. After both the 12 o'clock and 6 o'clock canal
incisions are made (Fig 1A), a posterior flap is elevated
toward the anulus, exposing the posterior aspect of the
bony canal (Fig 1B).
The bony canal is drilled from the lateral canal starting
with the spine of Henle toward the anulus using cutting
and diamond burs and constant irrigation and suction.
Drilling in one spot should be avoided. The bur should be
swept from side to side and up and down gently with even
pressure. Drilling is continued until the entire posterior
part of the anulus is visible. As drilling continues posteriorly, a few mastoid air cells may be exposed. Care should
be taken to avoid exposing too many mastoid air cells.
There is much more space for drilling in the posterior
superior and inferior directions.
A common problem at the time of a tympanoplasty is the
anterior bony overhang blocking one's view of the anterior
tympanic membrane and anulus. In order to expose the
anterior bony overhang, two types of anterior canal skin
flaps are used, either laterally based (Figs 1C, D) or
medially based (Figs 1E, F). The laterally based anterior
skin flap is elevated after making an incision a few
millimeters from the anterior anulus from 12 o'clock to 6
o'clock using a curved round canal knife. The anterior
bony overhang is drilled using primarily diamond burs
and suction irrigations. Drilling is continued until a full

OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY--HEAD AND NECK SURGERY, VOL 7, NO 1 (MAR), 1996: PP 27-33

27

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FIGURE 1. Canalplasty as a part of tympanoplasty. (A) Standard canal incisions are made at the 12 and 6 o'clock positions. (B) A
posterior flap is elevated toward the anulus, and the posterior bony overhang is drilled until the entire posterior part of the anulus is
visible. (C) The laterally based anterior skin flap ("windowshade flap") Js elevated after making an incision a few millimeters parallel to
the anterior anulus. (D) The anterior bony overhang is drilled until a full circumferential view of the anulus is achieved. (E) A medially
based anterior canal skin flap is developed with an incision at the lateral end of the bony canal and the flap is elevated toward the
anulus. (F) The anterior bony overhang is drilled. (G) After both posterior and anterior bony overhangs are removed, a full 360 view of
the anulus is possible.

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.~ ~ : : , .,,;.,, .;.-...

FIGURE 2. Canalplasty
for exostosis. (A) A canal
incision or a separate
incision on the exostosis
paralleling the anulus is
made. (B) The exostosis is
exposed by raising medial
and lateral canal skin flaps
and is drilled out. (C) After
the exostosis is removed,
the canal skin flaps are laid
back and packings are
placed.

C
. - .....
. ~ ' P Z . . ~ , . . .

flF
TIMOTHY T.K. JUNG

FIGURE 3. Canalplasty for

refractory external otitis. (A) A
postauricular incision is made
and the cartilaginous canal is
sectioned. (B) A circumferential
through-and-through incision is
made at the meatus. (C) A
diseased stenotic plug of canal
skin is removed along with the
infected meatus and outer
squamous layer of the tympanic
membrane. The bony canal is
widened by drilling.
29

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,,. ..,.~....12

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FIGURE 4. Canalplasty for refractory external otitis (continued). (A) A split-thickness skin graft, approximately 1 3 inches and
0.01-inch thick, is harvested from the upper medial surface of the arm, using a dermatome. (B) The harvested skin is laid skin-sidedown on a piece of Owen's silk impregnated with garamycin ointment and is cut into two pieces, one shorter with a concave edge, and
the other convex and longer, both the width of a standard wooden tongue-blade. (C) An alternative method of harvesting skin is to use a
razor blade as in a Thiersch graft

circumferential view of the anulus is achieved. Care must

be exercised to avoid entering the temporomandibular
joint. A medially based anterior canal skin flap begins with
an incision at the lateral end of the bony canal. The anterior
canal skin flap is elevated toward the anulus, and the
anterior bony canal is drilled in the same manner. After this
part of the procedure is finished, a full 360 view of the
anulus should be possible (Fig 1G). A canalplasty improves
exposure of the mesotympanum, making it possible to do a
better tympanoplasty.
EXOSTOSIS

Large exostoses can cause retention of cerumen, recurrent inflammation of the canal skin, and even conductive
hearing loss. An endaural approach or a transcanal approach is usually adequate. A posterior skin flap is developed from the bony cartilaginous junction to the anulus of
the tympanic membrane (Fig 2A). 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 top of the exostosis itself, paralleling the

30

anulus. Two skin flaps are developed over each exostosis,

one laterally and the other medially based.
After the posterior bony canal with exostosis is exposed,
the exostosis is drilled out with a cutting or diamond bur
using continuous suction and irrigation (Fig 2B). As the
base of the exostosis is removed, the entire tympanic
membrane comes into view. The anulus is left intact, and
the middle ear is not entered. The remaining bony canal
wall is smoothed down until the canal has normal, even
contours.
Any other exostosis in the canal is removed in a similar
manner. For an exostosis in the anterior canal or a coexisting anterior bony overhang, a laterally based anterior canal
skin flap is developed beginning from a few millimeters
lateral to the anulus. 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 out, the skin flaps are laid back (Fig
2C). The external auditory canal is packed with Gelfoam
saturated in antibiotic solution, or Owen's silk strips

CANALPLASTY

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FIGURE 5. (A) The longer convex piece of skin is laid out on the drumhead and posterior half of the canal. The shorter concave piece
covers the anterior half of the canal. (B and C) A "rosebud" packing is placed with strips of Owen's silk and pieces of cotton balls
saturated in an antibiotic steroid suspension. (D) A second pack may be placed lateral to the first pack.

(Davis-Geck, Danbury, CT) and pieces of cotton packing

(rosebud packing). The lateral part of the canal and the
meatus are packed with 0.5-inch gauze strips saturated
with antibiotic ointment.
The incision is closed in layers, and a mastoidectomy
type of pressure dressing is applied.
REFRACTORY

EXTERNAL

OTITIS

This procedure is indicated when chronic external otitis

is persistent despite intensive medical treatment. Refractory infection is often accompanied by drainage, pain, and
hearing loss. The canal is obliterated with swollen, thick
canal skin as well as newly formed bone, leading to an
acquired stenosis of the external canal. 2
A postauricular incision is used for wide exposure,
although an endaural or a transcanal approach may be
used. The cartilaginous canal is sectioned at the level of the
mastoid cortex through the postauricular incision (Fig 3A).
In addition, a circumferential through-and-through incision is made at the meatus (Fig 3B). Instead of a postauricular incision, the procedure may start with this type of
meatal incision. Diseased stenotic plugs of canal skin are
removed, including the outer squamous layer of the
tympanic membrane (Fig 3C). Perforation of the tympanic
membrane should be avoided at this step. If a small tear

TIMOTHY T.K. JUNG

occurs, the edges are approximated; for larger defects, a

fascial graft is used.
The bony canal is widened circumferentially by drilling,
using cutting and diamond burs under continuous irrigation and suction, until the entire tympanic membrane and
anulus are visible. Care must be taken to avoid entering the
temporomandibular joint anteriorly or the mastoid air-cells
posteriorly.
A meatoplasty is performed by removing the infected
narrow meatus and conchal cartilage (Fig 3B). The anterior
cartilaginous canal skin toward the tragus can be removed
if it is diseased. The meatus should be large enough to
admit a forefinger.
After the diseased canal skin and the meatus are removed and the bony canal wall is widened, a splitthickness skin graft 0.01-inch thick and I by 3 inches wide
is harvested from the upper medial surface of the arm with
a dermatome (Fig 4A). The harvested skin is laid skin-sidedown on a piece of Owen's silk impregnated with garamycin ointment, which helps to handle a piece of skin much
better. The skin with the Owen's silk backing is cut into
two pieces, one shorter piece with a concave edge for the
anterior canal wall and another convex and longer piece to
cover the posterior canal wall and drumhead. This step can
be done without the Owen's silk backing also. The width

31

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FIGURE 6. Tumors of the canal. (A) A biopsy can be done under local anesthesia with a cup-biopsy forceps. (B) If the lesion is small, a
wide excision as made with surrounding canal skin. (C) For the anterior canal tumor, excision can be extended to the tragus and the
tympanic membrane. (D) The anterior bony canal is thinned with a drill, and a split-thickness skin graft from the upper medial arm is
used to cover the exposed bone and the drumhead.

and convexity of a standard wooden tongue blade provide

a good guide for cutting the skin (Fig 4B). The longer piece
is laid out on the drumhead and covers from the anterior
anulus to the posterior half of the canal, and the shorter
piece covers the anterior half of the canal from the anulus
toward the tragus (Fig 5A). All exposed surfaces are
completely covered. An alternative method of harvesting
skin is to use a razor blade as in a Thiersch graft (Fig 4C).
A double-packing method is used, although a single
large "rosebud" packing works just as well. The first pack
places strips of Owen's silk-gauze and cotton, saturated in
an antibiotic steroid solution, medially against the drumhead in a "rosebud" fashion (Figs 5B and C). The second
pack is placed lateral to the first and usually consists of
0.5-inch gauze coated with an antibiotic ointment (Fig 5D).
The second pack is brought out through the auditory
meatus and helps stent the newly created larger meatus. In
one packing method, one larger "rosebud" packing is
placed up to the meatus. Any excess skin can be trimmed
off. A pressure dressing is applied over the ear. The packs
are removed after 2 weeks. Crusting may occur for several

32

weeks and requires meticulous removal and cleansing

until complete healing takes place.

TUMORS OF THE CANAL

Benign or malignant tumors may develop in the external
auditory canal. The canalplasty technique may be used to
excise these tumors. The method of excision depends on
the type and the extent of the tumor and its location in the
canal. Tumors that cannot be treated with the technique of
canalplasty, such as an extensive tumor requiring temporal
bone dissection, are excluded from this discussion. When a
tumor is found in the canal, the location, size, and extent of
the tumor should be thoroughly evaluated under an
operating microscopy. Malignancy should be suspected
whenever otalgia or bleeding is associated with the tumor.
Either CT or MRI are helpful in defining the extent of a
tumor. After a thorough examination, a biopsy should be
performed with local anesthesia using a cup-biopsy forceps (Fig 6A). If the lesion is small and has not penetrated
to the underlying bone, a wide excisional biopsy that

CANALPLASTY

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FIGURE 8. Tumors of the canal (continued). Tumors located at

the posterior canal can be excised with a margin, and a splitthickness skin graft may be used.

extensive and involves the middle ear or mastoid, subtotal

or total temporal bone resection may be necessary.
FIGURE 7. Tumors of the canal (continued). If the anterior canal
tumor is malignant, adequate excision may include
parotidectomy and removal of the anterior canal wall.

includes removal of surrounding canal skin is adequate

(Fig 6B).
For anterior canal tumors, the excision can be extended
up to the tragus and the tympanic membrane (Fig 6C). The
anterior bony canal is widened with a drill, and a splitthickness skin graft from the upper medial arm is used to
cover the exposed bone and the drumhead (Fig 6D). If the
tumor is malignant, lymphatic fluid may spread through
Santorini's fissures into the preauricular nodes. An adequate excision may include a superficial parotidectomy
and a removal of the anterior canal wall. If the tumor has
extended anteriorly and medially, the excision should
include the cartilaginous and bony anterior canal wall, the
anterior drumhead, the superficial lobe of the parotid
gland, and the condyle of the mandible (Fig 7). The defect
in the canal is covered with a split-thick-ness skin graft.
Tumors located at the cartilaginous posterior canal can
be excised with a margin (Fig 8). If the defect is large, a
split-thickness skin graft may be used. When a tumor is in
the posterior bony canal closer to the tympanic membrane,
wide areas of posterior canal skin with the epithelial layer
of the drumhead can be removed, and a split-thickness
skin graft is applied. The posterior canal can be widened
with a drill before the skin graft is applied. When a
malignant tumor is small and has not extended to the
drumhead, a complete modified radical mastoidectomy is
done. If the tumor is close to the drumhead, a radical
mastoidectomy is performed. If a malignant tumor is

TIMOTHY T.K. JUNG

COMPLICATIONS
Primary complications of canalplasty are drilling accidents. The temporomandibular joint may be exposed. A
small area of exposed joint causes minimal problem. When
a large area of joint is exposed, the patient's anterior canal
wall moves back and forth whenever his or her mandible is
moving. The condyle of the mandible may collapse the
anterior canal-wall into the canal. Mastoid air cells may be
opened as the posterior canal is drilled. A small defect can
be ignored, but a larger defect should be grafted with
fascia, cartilage, or bony plate. The tympanic membrane
may be torn while peeling the squamous epithelium or
while drilling. Skin flaps, or rarely ossicles, may be damaged from a drilling accident. Careful use of drills can
prevent these complications.
When the canal skin is badly infected with Pseudomonas,
postoperative infection may occur. The infection may
extend to cause perichondritis of the auricle. This type of
complication can be prevented by prophylactic treatment
with anti-Pseudomonal antibiotics such as ciproflaxicillin,
parenteral ceftazidime, or aminoglycosides.

REFERENCES
1. Jung TTK:Externalear canal procedures, in GoycooleaMV, Paparella
MM, Nissen RL (eds): Atlas of Otologic Surgery. Philadelphia, PA,
Saunders, 1989,pp 149-158
2. PaparellaMM, MeyerhoffWL, Morris MS, Da Costa S: Surgeryof the
externalear,in PaparellaMM,ShumrickDA(eds): Otolaryngology,3rd
ed, vol II. Philadelphia,PA, Saunders, 1991,p 1259

33