Technique

Surgery is usually performed using a CCD camera and video monitor, but if the endoscopy is expected to be a brief inspection, then viewing through the eyepiece is satisfactory and requires less setup time. Endoscopes with 30- and 70-degree view angles are most commonly used to inspect recesses. It is preferable to use the largest diameter suitable for introduction into the surgical field while allowing sufficient room to pass surgical instruments. Larger-diameter endoscopes yield superior image...

Preoperative Tests

In general, postoperative air-bone gaps are larger than preoperative ones when the stapes superstructure is involved by diseases. Though rare, operation on the wrong ear has happened. Therefore, verify the correct ear to operate upon with the audiogram immediately before the surgery. 2. Although not a prerequisite for tympano-mastoidectomy, a thin-cut computed tomography (CT) scan of the temporal bone is routinely ordered as part of the preoperative evaluation at...

Harvesting Fascia

The scrub nurse holds the superior edge of the wound laterally with a small retractor to help visualize the fascia. We attempt to harvest true fascia for the reasons previously mentioned. Fascia of the temporalis muscle posteriorly is ideal, as anteriorly the fascia thickens and occasionally splits with adipose tissue interposed. An incision is made in the fascia superior and parallel to the linea tempor-alis, and then a delicate iris scissors is used to harvest simply the fascia without...

Implant Design

Design of the prosthesis requires understanding of the acoustic mechanisms involved in the middle ear, as well as the anatomic and acoustic changes that occur with reconstruction. Reconstructing a defect in the ossicular chain requires adequate conduction of sound energy from the tympanic membrane to the stapes footplate. This must take advantage of the lever mechanisms inherent in the middle ear and transmitting the energy in a piston-like manner from the manubrium of the malleus to the...

References

The restoration of the function of the middle ear in chronic otitis media. Ann Otol Rhinol Laryngol 1971 80 210-217. 2. Zollner F. The principles of plastic surgery of the sound conducting apparatus. J Laryngol Otol 1955 69 637-652. 3. Gan RZ, Dyer RK, Wood MW, Dormer KJ. Mass loading on the ossicles and middle ear function. Ann Otol Rhinol Laryngol 2001 110 478-485. 4. Merchant SN, Ravicz ME, Puria S, et al. Analysis of middle ear mechanics and application to diseased and...

Embryology

The development of the inner ear, derived from the otic capsule, is greatly independent of the development of the middle ear and outer ear, which take their form from the first and second branchial structures.15 The external ear develops around the primitive meatus by the fusing of the six primitive hillocks, derived from the first and second branchial arches (Table 22-1), the auricle assuming its primitive form by the end of the third month of development. The external auditory meatus develops...

Patient Presentation and Initial Examination

Patients present with the primary complaint of hearing loss. The hearing loss usually develops insidiously between puberty and the age of 30. Often, patients delay seeking assistance for 2 or 3 years.6 The family history may or may not be positive for hearing loss treated by surgery. Numerous authors in reviewing their experience have found that about 50 of patients have a positive family history.7,8 A sibling of a patient with otosclerosis has only about a 1 in 10 chance of developing...

Facial Recess

The facial recess is bordered superiorly by the fossa incudis, medially by the facial nerve, and laterally by the chorda tympani (Fig. 13-5). It occasionally allows the extension of middle ear disease into the mastoid other than from the antrum. Opening the facial recess provides additional mastoid aeration. In cochlear implantation the electrode is inserted into the cochlea through the facial recess. The surgeon may begin drilling along an imaginary line between the digastric ridge and the...

Surgical Technique

The patient is placed in a supine position. The posterior surface of the earlobe is injected with 0.5 cc of buffered 1 lidocaine with epinephrine 1 100,000. The external auditory canal is injected similar to stapes surgery. The ear lobe is prepped and draped in a sterile fashion. A 5- to 10-mm incision is made in the ear lobe skin down to the subcutaneous fat. It is easier to remove the fat if the incision is placed along the edge of the ear lobe. In women, it is preferable to make the incision...

Reconstruction of the Middle Ear Ossiculoplasty and Insertion of Tubes

Finally, an ossiculoplasty may be performed in the newly cleaned space the techniques for this are discussed elsewhere in the literature. The malleus is lateralized by visualizing it endoscopically or microscopically, or feeling for it with the incudostapedial joint knife then the tensor tympani tendon is severed. When the stapes is stabilized, the handle of the malleus can be lateralized 1 or 2 mm to allow for a larger middle ear space, but lateralization must be carefully balanced with...

Definitions Evaluation

The current era of tympanoplasty began in 1952 with Wullstein and Zollner.1 Shea,2,3 Hough,4 Storrs,5 Herrmann,6 Austin,2,7,8 Sheehy,9,10 Glasscock,11,12 Tos,13 15 and others have since made important contributions. Today tympanoplasty is a highly developed set of techniques. Most tympanic membrane perforations can be closed with underlay or overlay techniques regardless of location or size.11,16 18 This chapter presents the technique of tympanic membrane repair with underlay grafting. In the...

Operative Procedures

Many different techniques have been developed over the past 50 years in an attempt to close perforations and several materials have been used for grafting material. Initially, split or full-thickness skin grafts were employed. The material was readily available near the operative site and was inexpensive, autologous, and readily shaped. However, many cases of improper growth of squamous epithelium either within the TM or in the middle ear occurred with this technique, leading to the search for...

Future Progress

Minimally invasive endoscopic techniques are rapidly developing, but the gains in optics have outpaced progress in appropriate operative tools. Extralong angulated dissectors, angulated suctions, combined laser endoscopic probes, and specialized forceps are being designed and tested. Suction-dissectors improve on the one-handed techniques that are currently required when hand-holding an endoscope. A practical endoscope holder may become available in the future but will always need to be used...

Stenosis

Battista and Carlos Esquivel The external auditory canal may be affected by numerous pathologic conditions. Over time, these conditions may result in narrowing of the canal with eventual stenosis. For the sake of discussion, the pathologies that cause stenosis can be broadly categorized as either bony or soft tissue. Both bony and soft external canal stenoses are unusual otologic conditions. Modified mastoidectomy was considered the treatment of choice in early reports of acquired...

Results of Micro Wick Usage

Since August 1998, over 200 patients in our clinic have been treated using the polyvinyl acetate Micro-Wick.14 When retrospectively reviewing the first 114 patients, the majority of the patients (92) were treated for Meniere's disease. The remaining 22 had a diagnosis of sudden deafness or autoimmune inner ear disease. Not all patients have complete follow-up data, so results include patients for whom long-term follow-up data are available. Patient acceptance of the procedure has been...

Atticotomy and Cleaning of the Middle

After canaloplasty, the middle ear can be entered by elevating a tympanomeatal flap inferiorly, elevating the annulus out of its groove, and extending the elevation superiorly to the notch of Rivinus. Then using a stapedial curette, a customized anterior atticotomy is achieved by removing the posterior canal wall at the level of the annulus. If the anatomy necessitates fuller visualization of diseased tissues, to eradicate them and enlarge the middle ear space, the atticotomy can be extended to...

Anterior Hypotympanotomy

The anterior hypotympanotomy is indicated for the removal of cholesteatoma primarily involving the hypotympanum and sinus tympani, which develop as a complication of adhesive otitis media or an atelectatic drum.1 As a result of the cholesteatoma removal and chronic eustachian tube dysfunction, the middle ear frequently heals with fibrosis, despite the best efforts to preserve a middle ear air space. Following a hypotympanotomy, the middle ear FIGURE 7-6 (A) The cholesteatoma and ossicular chain...

Classification

Several classification schemes have been described to define the severity of canal atresia as well as to predict the likelihood of successful hearing restoration surgery. Classification systems can be helpful in choosing appropriate surgical candidates, in counseling patients, and in analyzing and comparing results. The first widely used classification system, descriptive in nature, was proposed in 1955 by Altmann16 (Table 22-2). In 1985 De la Cruz13 proposed a further classification of Altmann...

Surgical Preparation

Most patients undergo general anesthesia with endotracheal intubation for this type of surgery. After the general anesthesia with endotracheal intubation is secured, the patient is then turned 180 degrees, and the surgeon sits at the surgical side of the patient with the scrub nurse across the patient from the surgeon. An area of hair is removed from around the ear for approximately 2 cm above and behind the auricle. The natural oils of the skin are removed with alcohol solution or acetone,...

Managing Pervasive Eustachian Tube Dysfunction

We have developed distinct criteria for primary intubation of cartilage tympanoplasties that comprise craniofacial abnormalities, including Down syndrome previous head and neck cancer involving the nasopharynx and patients with a history of multiple ear surgeries with demonstrated eustachian tube dysfunction. The perichondrium cartilage island graft is harvested and prepared as previously described. Using a round knife, a window that is large enough to allow placement of a Xomed Modified Goode...

Cerebrospinal Fluid Leak

Cerebrospinal fluid leaks occur in 1.4 of injuries involving the temporal bone.29 The great majority 6k tensive loss, Ly in panic and proximal vertical segment FIGURE 18-5 (A) Donor graft in place through the middle fossa approach. (B) Graft through the translabyr-inthine approach. 6k tensive loss, Ly in panic and proximal vertical segment FIGURE 18-5 (A) Donor graft in place through the middle fossa approach. (B) Graft through the translabyr-inthine approach. resolve spontaneously with...

Positioning and Preparation Instrumentation

The positioning of the patient is key in all otologic surgery. For the CWU mastoidectomy, the patient should be positioned on the operating table such that the head is located at the foot of the bed. This allows the surgeon's knees to fit comfortably underneath the table when seated. Also, the bed controls should be easily within reach of the anesthetist, as rotation of the bed is necessary throughout the procedure. The patient should be securely strapped to the table to allow for rotation of...

Anatomy of the External Ear Canal

The adult external ear canal is cartilaginous in its outer third and osseous in its inner two thirds. The average ear canal length is 6.5 cm, with an average diameter of 2.5 cm. At the junction of the cartilaginous and bony canal there is a slight angulation the cartilaginous part is inclined slightly posterosuper-iorly, and the bony part is inclined anteroinferiorly. As a result, the axis of the ear canal follows a lazy S shape. The anterior canal bone is very thick above and below the head of...

Exposing the Ear Canal and Middle

Vascular Strip Ear

The area of the linea temporalis is palpated and then an incision is made along this line, between the temporalis muscle and the ear canal. A T incision is made through the tissue overlying the mastoid to the mastoid tip. A Lempert periosteal elevator is used to expose the mastoid bone, and the spine of Henle is visualized. The self-retaining retractor is placed in this deeper plane. Now with the use of the operating microscope, a smaller periosteal elevator in the surgeon's right hand and a...

Dennis I Bojrab and Andrew N Karpenko

Today the goal of successful tympanoplasty is to create a mobile tympanic membrane or graft with an aerated mucosal-lined middle ear space and a sound-conducting mechanism between the mobile membrane and the inner ear fluids. A review of the literature reveals that many techniques have been developed and employed successfully there is a rich history of the evolution of techniques to produce this end. This chapter gives a brief history of the evolution of the over-under tympanoplasty, and...

Operative Technique

Donaldson Line

After anesthesia induction and patient positioning, the postauricular incision is injected with 1 lido-caine with 1 100,000 epinephrine. The patient is prepped and draped as if for a tympanomastoidec-tomy. A No. 15 Bard-Parker blade is used to incise 0.5 cm posterior to the postauricular crease while palpating the mastoid tip to avoid excessive inferior dissection. The No. 15 blade is used to cut until the temporalis muscle superiorly and mastoid periosteum inferiorly is encountered. Blunt...

Floating Footplate

The footplate may inadvertently mobilize while it is manipulated. Regardless of whether it is solid (white) or diffuse (blue), a graft should be placed over it and a 4-mm prosthesis inserted. Long-term success rates with this technique are 97 within 10 dB if there is a blue footplate. If this occurs with a white footplate, hearing success is only 52 . However, this situation can often be safely revised. Should the footplate mobilize again during revision, no future surgery should be advised. In...

Mechanics of the Prosthesis

Ideally, a prosthesis should have its center of gravity perpendicular to its intended movement. In the majority of cases, this would lead to a center of gravity located directly over the capitulum or the oval widow. Such a center of gravity would provide maximal resultant force in the intended direction of the hearing mechanism. This would also minimize any risk of the prosthesis slipping off the capitulum or oval widow. Only a minority of designs, however, have a center of gravity centered...

Second Look Mastoidectomy

Endoscopic assistance in CWU mastoidectomy has significantly reduced the number of second-look procedures. When a second look is necessary, it can most often be done as a transcanal procedure because residual cholesteatoma most commonly occurs in the epitympanum, facial recess, or sinus tympani rather than in the mastoid cavity.14 McKennan15 described performing an endoscopic approach to the mastoid through a small postauricular stab incision and doing a separate middle ear exploration when...

Malleus Present

When the malleus handle is present, the modification of the palisade technique, as described above, is utilized. An acoustic benefit has been shown with the incorporation of the malleus in ossicular reconstruction, possibly due to the cantenary action of the malleus in the TM.32 Likewise, the presence of the malleus with an intact anterior malleolar ligament offers improved prosthesis stability by allowing precise length adjustments and ultimate fit, leading to optimal hearing results.45 This...

Canaloplasty

Lempert Incisions

Most patients with chronic otitis media have small external ear canals that bulge into the anterior and often also the posterior canal. Generous canaloplasty, tailored to each patient, is usually required. Using self-retaining retractors, skin of the anterior canal is elevated in a laterally based flap, and skin of the posterior canal in a medially based flap. A highspeed cutting drill under suction irrigation is used to enlarge the circumference of the posterior canal, removing the spine of...

Conductive Hearing Loss

Blood Clot Ear Canal

Conductive hearing loss can result from injury to the middle ear with or without temporal bone fracture. Often the injury causes bleeding from the external auditory canal skin. If CSF otorrhea also is present, the clot should be left alone to form a natural biologic dressing as the CSF leak usually stops spontaneously (see below). If no leak is present, under appropriate magnification blood can be gently cleaned in an attempt to delineate if the source of bleeding is the external or middle ear....

Ossicular Coupling

Ossicular coupling refers to the sound pressure gain that occurs through the actions of the tympanic membrane and the ossicular chain. The pressure gain provided by the normal middle ear with ossicular coupling, however, is frequency dependent. The mean middle ear gain is approximately 20 dB at 250 to 500 Hz, reaches a maximum of about 25 dB around 1 kHz, and then decreases at about 6 dB per octave at frequencies above 1 kHz.8 Certain portions of the tympanic membrane move differently depending...

Managing Cholesteatoma

Cholesteatoma represents one of the most controversial but important pathologic conditions where cartilage is used. The primary purpose of cholestea-toma surgery is to eradicate disease and provide a safe, hearing ear. The magnitude of the controversy with regard to optimal surgical management is beyond the scope of this discussion, but cartilage should arguably be involved in each technique. A technique involving partial canal wall removal for cholesteatoma extirpation, followed by cartilage...

Endoscopy of the External Auditory Canal and Tympanic Membrane

Endoscopes are useful in the office for inspecting areas of the ear that are inaccessible to the operating microscope and for photodocumentation. The panoramic views achieved with a 2.7- or 4-mm endoscope are excellent for otologic photography. Endoscopes are useful to inspect the tympanic membrane or medial external auditory canal when the microscopic view is limited by canal stenosis or other obstructions. Defects or recesses in the external canal and the depths of mastoid cavities may be...

Harvest of the Cartilage Graft

Cartilage for TM reconstruction is typically harvested from two areas' the tragus and the cymba' depending on the type of reconstruction to be performed. The perichondrium cartilage island flap is nearly always constructed with cartilage harvested from the tragus. This cartilage is ideal because it is thin' flat' and in sufficient quantities to permit reconstruction of the entire TM. The cartilage is used as a full-thickness graft and is typically slightly less than 1 mm thick in most cases....

Types of Congenital Malformations of the Facial Nerve

In the middle ear, two most common facial nerve anomalies are nerve displacement (Fig. 13-1) and fallopian canal dehiscence. The nerve may be found at the level of the promontory and covered only by respiratory mucosa. It may be found inferior to or at the level of the stapes or oval window. Sometimes the stapes superstructure ends blindly in the soft tissue substance of the facial nerve. The facial nerve may also bifurcate around an intact stapes, and the split nerve may or may not remain...

Preparation of Tympanic Membrane Remnant

When the disease process is under control, the tympanic membrane remnant is prepared for grafting. A rim of tissue is removed from the perforation edge to remove diseased tissue or mucosal thickening and encourage migration of healthy epithelium and the mucosal layer. For those patients where an over-under tympanoplasty is to be employed, the malleus is clearly visualized by elevating the tympanic membrane. The periosteum of the malleus is incised with a fine sharp needle (Fig. 5-2). This...

Conclusion

Ossicular chain problems are frequently encountered in otologic surgery and are amenable to reconstruction. Because various materials are used for ossiculoplasty, it is important to determine which type of prosthesis is appropriate. This decision is based on the status of the diseased ear and the surgeon's preference. Considerations must be made for the presence or absence of the malleus, the anatomic relationship of malleus to stapes, the severity of eustachian tube dysfunction, and tympanic...

Postoperative Course Prognosis

The mastoid dressing is removed by the patient on the first postoperative day. The patient is placed on prophylactic antibiotics for 5 days. Strict water precautions are observed using a cotton ball saturated with petroleum jelly or bacitracin ointment in FIGURE 23-7 (A) Thin split-thickness skin graft with notch for bend at anterior sulcus. (B) Skin graft covering tympanic membrane and ear canal. FIGURE 23-7 (A) Thin split-thickness skin graft with notch for bend at anterior sulcus. (B) Skin...

Prosthesis Materials

The ideal material for ossicular reconstruction should meet three principal criteria. First, the material must be stable in the middle ear environment. There should be minimal if any rejection phenomena to avoid any granulation tissue formation or subsequent degradation of the reconstruction. Second, the material should present no risk of interaction in the middle ear environment. in reference to this, the reconstruction should minimize the risk of infection or deleterious chemical reaction in...

Postauricular Exposure and Harvesting of Temporalis Fascia

The skin incision begins at the anterior extent of and 1 cm above the postauricular fold. It is carried forward inferiorly, either in or just posterior to the postauricular crease, to the level of the floor of the external auditory canal. This allows adequate exposure of the bony external canal when the ear is retracted forward. A large piece (2 x 3 cm) of temporalis fascia is harvested, cleaned of any adherent muscle or fat, and pressed for 5 minutes. It is then dried under a heating lamp. The...

The Loose Areolar Fascia Graft

The graft is cut to a square about 4 x 4 mm, about the size of a cigarette in diameter. It is purposely FIGURE 15-5 Laser technique for cutting the posterior crus. FIGURE 15-6 Laser technique for cutting the anterior crus. Remove the stapes superstructure. FIGURE 15-5 Laser technique for cutting the posterior crus. FIGURE 15-6 Laser technique for cutting the anterior crus. Remove the stapes superstructure. FIGURE 15 7 Laser technique for creating the rosette on the stapes footplate. kept very...

Causes Pathophysiology

The most common bony diseases that may cause stenosis of the external auditory canal are exostosis, osteoma, and fibrous dysplasia. Exostoses of the external canal are rounded, multiple bony outgrowths that can occur because of chronic irritation of the external canal. The most common cause of exostoses is cold-water swimming. These lesions can continue to grow even after the ear canal is no longer exposed to a cold environment. Osteomas are singular, often pedunculated, benign bony tumors...

Postoperative Care

Postoperative care varies depending on whether the canal wall has been preserved. In a CWU procedure, the patient returns in 3 weeks for debridement of the external auditory canal. Under the operating microscope any crusting is removed from the ear canal, and evidence of infection is noted. The tympanic membrane is inspected with removal of any debris. Antibiotic otic drops are used if infection is present. Only in the case of extensive canal swelling should oral antibiotics be considered....

Underlay Undersurface Technique

The underlay or undersurface technique employed grafting material medial to or under the remnant tympanic membrane, typically under the malleus when the perforation extended to that area. The free edges of the perforation are prepared using a right-angled hook. The intent is to separate the outer cutaneous layer from the inner mucosal layer. This develops a fresh edge for healing. This technique originally described by Shea in 1957, was used initially for iatrogenic tympanic membrane...

Endoscopy in Chronic Ear Surgery

Endoscopes may be employed in chronic ear surgery as an adjunct for the removal of cholesteatoma.8 12 Residual disease most commonly occurs in the areas most difficult to expose under the operating microscope including the epitympanum, sinus tympani, and facial recess. Endoscopes are helpful to inspect these recesses and may be used to confirm the eradication of disease after microsurgical excision or to assist in the primary dissection of cholestea-toma. Tympanic membrane retraction pockets...

The High Risk Perforation

The high-risk perforation, defined as a revision surgery, a perforation anterior to the annulus, a perforation draining at the time of surgery, a perforation larger than 50 , or a bilateral perforation, has been shown to be associated with increased failure rates using traditional techniques. In these cases, cartilage has proven extremely valuable for reconstruction of the TM. Revision tympanoplasty has been shown by numerous authors to be a risk factor for subsequent failure in graft take and...

Normal Tympanic Membrane

Embryologically, the tympanic membrane is derived from the fusion of the ectodermal meatal plugs from the first branchial cleft and the endodermally derived first branchial pouch (tubotympanic recess). The tympanic membrane and middle ear cavity is the area of contact between these two structures. The tympanic membrane separates the delicate middle and inner ear structures from the external environment. It measures approximately 10 mm in diameter, and is conically shaped with the apex of the...

The Oval Window Covering

What material to use for grafting the open oval window has been widely discussed. Blood, fascia, vein, and other tissues have been described. A study in the 1960s addressed the idea of the characteristics of the ideal grafting material.23 Fascia and vein are comparable in metabolic rate. Vein creates a very thin membrane. Thick fascia may be difficult to mold to the shape of the oval window. Loose areolar connective tissue ''moon glue'' is one of the more ideal tissues, being composed of...

The Footplate

All of the previous steps were preparatory to addressing the stapes footplate. These previous steps should have been completed without difficulty prior to proceeding. The reason for this caution is clear No harm has been done to this point. If something FIGURE 15-4 (A) Cutting the incudostapedial joint. (B) Dividing the stapedial tendon. FIGURE 15-3 Curetting the bone from the scutum. FIGURE 15-4 (A) Cutting the incudostapedial joint. (B) Dividing the stapedial tendon. has gone awry, the...

Postauricular Closure and Placement of Vascular Strip

The retractors are removed and the vascular strip is replaced anteriorly in the bony canal. The periosteal layer is closed over the mastoid cortex or the mastoidectomy defect. Transmeatally, the vascular strip is elevated and pulled forward to uncurl it to its full length. It is then replaced along the posterior canal wall and the remainder of the canal is packed with Gelfoam. The postauricular incision is closed subcutaneously followed by Steri-Strips, and a standard mastoid dressing is...

Foreword II

Middle ear and mastoid surgical procedures constitute the vast majority of otological procedures utilized by the general otolaryngologist, head and neck surgeon (often 50 of those practice), and especially by the otologist-neurotologist. There are a number of other textbooks that discuss otology as a whole, including information regarding pathogen-esis of the many hundreds and even thousands of ear diseases. The recent literature with emphasis on molecular biological studies, including...

Discussion

Patients who have never had otologic surgery or whose prior surgery preserved the bridge or canal wall can undergo an IBM procedure. Our results with it have been gratifying when compared with results for either open-cavity or closed-cavity tympa-nomastoidectomy. The IBM can achieve improved hearing (as in intact-wall techniques) and eradicate cholesteatoma (as in open-cavity techniques). In the small, sclerotic mastoid common to these patients, the IBM approach allows wide exposure of the...

Maintaining the Middle Ear Space

Once the reconstruction is complete, one must take the necessary steps to maintain a good reconstruction. The first step is the maintenance of an air-containing middle ear space during the immediate healing period. There are many options for maintaining this space. By far the most popular in the United States is the use of Gelfoam or Gelfilm. Gelfoam is a cellulose-based foam that is thought to be enzymatically degraded in 50 to 60 days by the middle ear. Major benefits are its easy insertion...

Receiver Bed and Electrode Array Trough

Preparation of the receiver bed begins by selection and design of the placement. It is important to place the receiver bed posterior enough to accommodate the ear level hook or behind-the-ear speech processor. Placement of the receiver bed in a position that is too far anterior is a common mistake made by inexperienced cochlear implant surgeons. The consequence of this misplacement is extrusion of the receiver following skin erosion due to the ear hook or behind-the-ear speech processor placing...

Surgical Procedure

Intraoperative facial nerve monitoring is useful in the transcanal removal of cholesteatoma, particularly as one approaches the level of the drum. The anterior atticotomy may be performed using an endaural (preferred) or postauricular incision. It is necessary to have wide exposure of the external auditory canal. The tympanomeatal flap is extended anterior to the short process of the malleus, at the 2 o'clock position in a right ear and the 10 o'clock position in a left ear (Fig. 7-1)....

Acoustic Coupling

Movement of the tympanic membrane produces a sound pressure in the middle ear that is transmitted to the oval and round windows. Acoustic coupling is due to the difference in sound pressures acting on these areas. The pressure at each window is different because of the small distance between windows and the different orientation of each window relative to the tympanic membrane. In normal ears, the difference in pressures between the oval and round windows (acoustic coupling) is negligible. In...

Rex S Haberman II and Michele St Martin

The canal-wall-up (CWU) mastoidectomy procedure was introduced by Jansen at the House Ear Clinic in 1958.1 His goal was to perform more conservative surgical excision of cholesteatoma or other chronic ear disease, preserving the normal anatomy of the external auditory canal. This procedure was developed as a way to address some of the disadvantages of radical and modified radical mastoidectomy, which can include a lifelong need for cleaning of the mastoid cavity and for avoidance of swimming...

Surgical Findings

Long Process Incus

''Prior to undertaking revision stapes surgery, it is helpful for the otologic surgeon to know what problems he The most common finding at revision surgery is related to prosthesis dysfunction, which is reported to occur in perhaps up to 80 of the cases. The most common intraoperative findings, as cited in the literature, are summarized in Table 16-1. But prosthesis dysfunction, like the other findings noted below, is unlikely to be the only problem detected at surgery. in more than 50 of the...

Facial Nerve Anomalies

The facial nerve is frequently dehiscent and this rarely presents a problem. When overhanging and yet some footplate is visible, a number 26 suction is used to gently push the nerve aside. This may allow enough access to the footplate for the operation to proceed. Alternately, first a Hough hoe and then a microdrill may be used to drill off the inferior margin of the oval window and promontory. Place the drill on the footplate, push aside the facial nerve with the suction, and gently sweep up...

Ossification of the Cochlea

During the opening of the cochleostomy if some ossification of the cochlea is encountered, but once drilling past 1 to 4 mm of the basal cochlea a normal scala tympani is encountered, then the compressed electrode array may be the appropriate array for insertion. The C40 compressed electrode (C40 S) is designed with the same number of electrode contacts (n 12 pairs), but the total length of the electrode array is 18 mm as compared to 31.5 mm. The C40 S electrode contacts are arranged closer...

Weight of the Prosthesis

The ideal weight of the prosthesis has been examined by a number of investigators. To date, the most compelling evidenced-based answer has been the result of laser vibrometer and finite element analysis studies at a number of institutions. Huttenbrink15 and others in Germany have studied this question in depth utilizing a combination of mathematical models and temporal bone simulations. Their findings indicate that the ideal prosthesis should be lightweight and rigid. The lightweight prosthesis...

Bone Anchored Hearing

Baha Abutment Infected

In the quest for complete hearing restoration, the cornerstone remains amplification. Many advances have been made in middle ear and chronic otomas-toiditis surgery. Despite these advances, there will always remain those patients who despite aggressive surgical interventions continue to drain or begin draining once the canal is occluded with a conventional air-conduction hearing aid. Likewise, there will continue to be congenital aural atresia in which reconstructive endeavors should not or...

Wullsteins Osteoplastic Flap

Attic Retraction Pocket

Sabrina Wullstein has popularized the creation of an epitympanic osteoplastic flap.13 This elegant procedure gives wide exposure of the epitympanum and mastoid antrum. Variations in the technique are more popular in the United States and Europe.14,15 The osteoplastic flap approach is begun like an anterior atticotomy, as previously described. The scutum is thinned but not drilled away as in the atticotomy. The scutum, the lateral epitympanic FIGURE 7-5 The external ear canal is enlarged as in...

Middle Ear Ossicular Status

Often the status of the middle ear mucosa and ossicular chain can be evaluated by careful examina tion through the perforation. A normal or near-normal mucosa predicts a favorable outcome. Likewise, an intact ossicular chain improves the prognosis for hearing improvement. Tympanosclerosis, a hyaline degeneration in the middle ear, is frequently seen in ears with chronic otitis media. Although tympanosclerosis rarely affects the success of the TM graft, it may contribute to ossicular fixation....

Procedure Room Setup and Equipment

The minimum size of the minor surgery room should be 150 square feet, although a larger room is preferable. Two instruments that are not standard to all otologic offices but contribute tremendously to the success of office-based otologic surgery are the C02 laser and the 1.7-mm rigid otoendoscope (Smith-Nephew Richards, Memphis, TN). The laser is instrumental in creating an instant, bloodless, and nearly painless myringotomy for middle ear aeration or other procedures. The otoendoscope provides...

Historical Review

The tympanoplasty operation is a surgical procedure to eradicate disease in the middle ear and to reconstruct the hearing mechanism, with or without mastoid surgery and with or without tympanic membrane grafting. This procedure was defined by the American Academy of Ophthalmology and Otolaryngology's Committee on Conservation of Hearing in 1964.10 Hippocrates11 himself recognized that ''acute pain of the ear, with continued strong fevers, is to be dreaded, for there is danger that the man may...

In Memoriam

This chapter is Frank Rizer's last contribution in otology. On March 20, 2003 Frank died tragically while landing his airplane in Washington, D.C., on his way to attending the Cherry Blossom Conference. For the last 18 years, he has practiced otology and neurotology with Bill Lippy and Arne Schuring in Warren, Ohio. He was an outstanding physician and surgeon with wide interests and will be missed by his family and patients, as well as his partners and colleagues. Stapedectomy is a remarkable...

Sudden Deafness and Autoimmune Inner Ear Disease Treatment Results

Nineteen patients were treated for sudden deafness. Five of the patients had a positive response to the self-administered dexamethasone. It appeared that patients treated early in the disease had better results, although one patient had a good response after more than 1 year. There was no statistically significant difference between patients treated in less than 4 weeks after their hearing loss and those who had a more than 4-week delay before treatment. Only three patients were treated for...

Surgical Approach

''Nowhere is the laser more appropriate than in revision stapes surgery.''22 in preparing to approach a failed stapes surgery, the availability of a laser is extremely important. A large meta-analysis demonstrated the significant benefit to outcome with the use of lasers as compared to conventional techniques in revision surgery. Wiet et al35 showed that a successful (< 10 dB) result occurred in 69 of cases treated with a laser, whereas only 51 attained the same result when conventional...

Middle Ear Aeration

The middle ear space must be well aerated to facilitate ossicular function and tympanic membrane motion. Middle ear air pressure is less than the external canal air pressure in normal conditions, providing an environment conducive to ossicular coupling. If middle ear aeration is poor and the space is reduced, the pressure of the middle ear increases relative to the external canal pressure as the impedance increases. The pressure difference leads to a reduction in ossicular and tympanic membrane...

Considerations in Graft Healing

The normal tympanic membrane has a complex layered structure consisting of thin stratified squamous epithelium on the lateral surface, flat respiratory epithelium on the medial surface, and two fibrous layers, one radial and one longitudinal, between the two epithelial layers. The fibrous layers also contain vascular elements. successful, functional repair of the tympanic membrane requires reconstitution of the epithelial layers and enough of a fibrous middle layer to provide satisfactory...

Transcanal Tympanomeatal Approach

Tympanomeatal Flap

This approach is to remove the isolated cholestea-toma limited to the middle ear often seen at the anterosuperior portion of mesotympanum. An incision is made on the posterior canal wall as in the stapes operation. A dissector is used to raise the posterior tympanomeatal flap to enter the middle ear (Fig. 14-2A). Exposure of the stapes, the oval and round windows, and the promontory is obtained by elevating the annulus. To expose the anterosuperior portion of mesotympanum, an incision is made...

Electrode Insertion

The electrode insertion is specific for each device, and the following subsections describe the technique used for each electrode insertion. The standard electrodes are described below, and descriptions of special electrode designs are provided in the section dealing with ossification of the cochlea. The Nucleus Contour electrode is a perimodiolar design and is preformed to conform to the modiolus. There is a stylet that is positioned within this electrode array that maintains the electrode in...

Bojrab Universal Prosthesis Design

The ideal prosthesis must be biocompatible, able to optimize sound conduction based on material and weight, and easily trimmed. The prosthesis must not extrude or move once placed. Failures with reconstruction occur from movement at either the lateral Table 19-4 Anatomic Variants that May Be Encountered in the Middle Ear and Solutions to the Problem Stabilization of prosthesis Stapes capitulum Stapes no capitulum Footplate normal Footplate abnormal Narrow Center ridge Tilted Slightly rounded...

Canaloplasty for Atresia

Driscoll Congenital aural atresia is thought to occur in 1 in 10,000 to 20,000 live births, with unilateral atresia being three times more common than bilateral atresia.1 3 It occurs more often in males, and more often on the right side.1 Although external ear and middle ear malformations often occur in combination, due to their similar embryologic origin from the first and second branchial structures, inner ear malformations are a less common association,...

Malleus Absent

The malleus-absent situation represents one of the most useful indications for cartilage tympanoplasty but one of the more challenging situations for ossicular reconstruction because there is no malleus enabling an exact fit between two essentially stable, bony platforms and allowing the surgeon to build the ossicular reconstruction to the TM. The cartilage tympanoplasty technique described below has proven useful to alleviate this problem. The perichondrium cartilage island flap from tragal...

Ossiculoplasty II

The goal of modern ossiculoplasty is the restoration of a stable sound transfer mechanism in the middle ear space. Typically this involves restoring the mechanical advantage of the tympanic membrane and the malleus without restoring the lever advantage of the incus. Unfortunately, published techniques and opinions on how to achieve this goal are numerous. With the exclusion of prostheses for stapes surgery, there are over 100 approved pros-theses on the market. Additionally, there are multiple...

Atelectatic Drum

The atelectatic ear represents the first and most well-described situation in which cartilage techniques have been utilized. Perichondrium and fascia have been shown to undergo atrophy after use in this situation11 however, numerous reports have established the efficacy of cartilage in TM reconstruction of the atelectatic ear.19,22,23 Much of the confusion associated with this disorder stems from a poor understanding of the underlying pathophysiologic conditions that ultimately lead to changes...

Soft Tissue Incisions and Approach

Over the years, several variations of scalp and skin incisions have been utilized in cochlear implant surgery. Although several flaps have been utilized with consistently good results, two fundamental principles must be adhered to first, the blood supply of the flap must be ample for survival of the flaps and second, the skin incisions must not overlie the cochlear implant itself. With this evolution in flap design has also come changes in philosophy regarding the amount of hair that must be...

The Mastoidectomy

The temporalis muscle is dissected superiorly from the dural line so that the root of the zygoma is well exposed. Here, the first cut of the drill with the largest cutting bur is made, brought back posteriorly and gently carried down so that the first landmark seen is always the level of the middle fossa tegmen. This structure will have a slight bluish to purplish hue. The rest of the mastoid dissection in the classical shape is then made, preserving the canal wall at first and establishing the...

Surgical Management

Blunting Anterior Canal Wall

The main goal of surgery is to restore and maintain patency of the external auditory canal for normal sound transmission and maintenance of the canal's self-cleaning functions. If the ear is actively discharging, it is best to decrease the inflammatory process with cleansing and topical steroid-antibiotic therapy. Surgery can proceed when the ear is no longer draining. FIGURE 23-1 Coronal computed tomography CT of soft tissue stenosis with cholesteatoma arrow medial to stenosis and lateral to...

Mastoidectomy

The initial surgical approach in revision mastoidectomy is not dependent on whether a CWU or CWD procedure is to be performed. The ear canal should be injected and a vascular strip should be outlined as in an initial tympanomastoidectomy. The postauricular incision should be carried down through the previous incision. If extensive scar tissue or keloid formation is present, the scar should be excised. A plane over the temporalis muscle should be identified and temporalis fascia should be...

Auditory Brainstem Implants

The first report of direct stimulation of human auditory cortex is attributed to Penfield in the 1950s, which was done under local anesthesia. In 1964 Simmons and his group described their experience with electrical excitation of the cochlear nerve and inferior colliculus. William House implanted the first auditory brainstem implant ABI with singlechannel electrode array in 1979 after removal of an acoustic tumor.15 Since 1992, advanced multichannel ABIs have been implanted. At the present ABI...

Perichondrium Cartilage Island Flap

The general technique of reconstruction using the perichondrium cartilage island flap begins with harvest of the cartilage from the tragal area.28 An initial cut through skin and cartilage is made on the medial side of the tragus, leaving a 2-mm strip of cartilage in the dome of the tragus for cosmesis Fig. 6-1 . The cartilage, with attached perichondrium, is dissected medially from the overlying skin and soft tissue by spreading a pair of sharp scissors in a plane that is easily developed...

Canal Wall Up or Down

When confronted with a revision mastoid procedure, the most important decision to be made by the surgeon is whether to preserve or remove the posterior canal wall. The differences between CWU and canal-wall-down CWD procedures should not be minimized. Hearing loss, aftercare, and the caloric effect produced by the exposed bony labyrinth are major drawbacks to the CWD procedure. On the other hand, a well-done CWD procedure results in a safe, dry ear, whereas a well-done CWU mastoidect-omy may...

Which Nerve Repair Should Be Carried Out Once the Pathology Is Identified

Once the facial nerve has been exposed and the location, type, and severity of pathology have been discovered, surgical repair can be performed. Findings at the time of facial nerve exploration include intraneural hematoma or contusion, bony impingement, and nerve transection. If hematoma is found, then facial nerve decompression should be carried out along the path of the nerve above and below the site of injury. Bony impingement should be removed, again followed by decompression. Should the...

Endolymphatic Sac Surgical Technique

Mastoid Shunt

The surgical suite is set up as it is for doing a mastoidectomy, with the bed turned either 90 or 180 degrees. The patient should be positioned with the nonoperative ear approximated to the contralateral shoulder. This improves visualization of the sac as it exits the labyrinth, toward the descending segment of the sigmoid sinus. As the endolymphatic sac may be in close proximity to the facial nerve, intraoperative monitoring should be considered. An incision is made just outside the...

The Ossiculoplasty Outcome Parameter Staging OOPS Index

Uncertain of the statistical validity of previously proposed systems, we examined over 200 ossiculo-plasties at our own institution, all of which had been performed by the same surgeon, to determine which factors best predicted outcome. These results were organized into the Ossiculoplasty Outcome Parameter Staging OOPS Index, as shown in Table 20-1.13 Parameters examined included age, diagnosis, perforation, Bellucci classification score, Austin classification, middle ear mucosa status,...

Indications for Over Under Tympanoplasty

By combining the benefits of both techniques, the over-under tympanoplasty has become the preferred technique for various approaches to tympanoplasty.41 43 This technique places the tympanic membrane fascia graft lateral to the malleus, but medial to the remnant of tympanic membrane or fibrous annulus. This allows excellent exposure to the anterior middle ear space and prevents media-lization of the graft to the promontory, and ossicular reconstruction may be placed directly to the underside of...

Middle Ear Exploration

Mastoid Exploration

Using a weapon or No. 2 canal knife, the tympano-meatal flap is elevated up to the annulus. With a No. 2 canal knife firmly against the bony canal, the annulus and a few millimeters of mucoperiosteum of the middle ear are lifted off the bony annulus. A Rosen needle or a sickle knife is used to tear the mucoperiosteum and enter the middle ear space near the hypotympanum. With the retraction of suction tip held by the other hand, the tear in the mucoperiosteum is widened and the middle ear space...

Special Considerations Regarding Securing the Electrode Array

Tympanic Membrane Pathology

For all three devices manufactured for the U.S. marketplace, securing of the electrode array at the cochleostomy site and at the facial recess is important. The cochlea and facial recess are the same size at birth as they are throughout adulthood and therefore, it is important to secure the electrode array at the cochleostomy with the fascia graft, which will scar in place and bridge the surrounding promontory to the electrode array. A second site of stabilization at the facial recess, with...

Middle Ear Implants

Ear Canal Wall Down Surgery

Implantable middle ear hearing aids directly drive the ossicular chain or its attachment by means of the implanted components. They are intended for use in patients with residual cochlear function who could benefit from amplification. Based on the different transducers used in the design, current technology offers two types of middle ear implants piezoelectric and electromagnetic. Piezoelectric implants use ceramic structures that are capable of temporary bending if electric current is applied....

Results

Tympanic Sulcus

Caution is advised in reading the literature on tympanic membrane repair because of uncontrolled variations in patient selection, and reporting methods Table 3-1 . Prospective, randomized, controlled clinical trials comparing groups undergoing underlay versus overlay tympanic membrane grafting do not exist. In author Monsell's experience, the socioeconomic status of the patient is an important factor in success with chronic ear surgery generally. In 1995, the American Academy of...

Mastoidectomy Facial Recess Approach and Cochleostomy Techniques

Facial Recess Mastoid

The important point in considering the mastoidect-omy for placement of a cochlear implant is that this is much smaller than that utilized for chronic ear disease. In contrast to the standard method of saucerizing the mastoid cavity, this is not performed in cochlear implant surgery. There are two areas that need to be skeletonized, and the single most important one of these is the bony external auditory canal. If the bony external auditory canal is not thinned appropriately, then the angle...

The Palisade Technique

Tragus Graft Tympanoplasty Procedure

In the palisade technique, the cartilage is cut into several slices that are subsequently pieced together, like the pieces of a jigsaw puzzle, to reconstruct the TM Fig. 6-5 . Because of the nature of the reconstruction, it is not necessary to have one large, flat piece of cartilage, and the more curved cymba cartilage, which is harvested from the postauricular incision, is suitable Fig. 6-6 . A large area of conchal eminence can be exposed by elevating the subcutaneous tissue and postauricular...

Incision

In a well-pneumatized mastoid, a postauricular incision is used to expose mastoid and middle ear sometimes, if the meatus is small, a limited endaural incision is added. In the more frequent sclerotic or diploic mastoid, however, Lempert endaural incisions I, II, and III are begun 5 to 7 mm from the tympanic annulus in the bony ear canal Fig. 10-1 . Then incisions are made at the 6 o'clock and 12 o'clock positions with a sickle knife, and a No. 1 knife at the tympanic annulus, to connect with...

Overlay Tympanoplasty

Hansen The modern era of tympanoplasty began in the 1950s with the work of Zollner1 and Wullstein2 using full-and split-thickness skin grafts to repair the tympanic membrane TM . Subsequent innovations included the use of other grafting material including canal skin, vein, perichondrium, and temporalis fascia.3 5 Modern approaches to tympanoplasty differ in whether the graft is placed lateral or medial to the TM remnant.6 10 This chapter describes lateral grafting...

Complications and Management

Failure of graft healing is usually due to improper placement of the graft due to technical error or inadequate exposure or infection. Office myringoplasty or revision surgery may be considered.32 Failure to achieve the desired improvement in hearing may occur because of failure of the graft to heal persistent perforation , recrudescence of disease, adhesions between the tympanic membrane and the promontory, or ossicular problems. An inclusion keratoma may form if a piece of viable squamous...