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 Henle and all overhangs to achieve a straight, direct, unobstructed approach to the tympanic annulus (Fig. 10-4).

If there is prominent bulging into the anterior canal that obscures the view of the drumhead, an incision is made in the anterior canal with a No. 2 knife lateral to the tympanic annulus in a semicircle from the 6 o'clock to 12 o'clock positions. The skin of the anterior canal is very carefully elevated using a duck-billed knife/elevator; then just past the bone-cartilage junction a thin skin flap is carefully raised with a larger, round, duller periosteal elevator (Fig. 10-5), being careful not to amputate the flap. A highspeed cutting drill with suction/irrigation is then used to make two grooves in the anterior canal wall, inferiorly and superiorly, and then connect them with drilling. This allows full visualization of the anterior drumhead by removing the bulge in the canal. Apparent distance to the temporomandibular

Lempert Incisions
Endaural incisions (Lempert 1, 2, 3} FIGURE 10-1 Lempert incisions.

Canal incisions for TM flap

Canal incisions for TM flap

Tympanic Membrane Incision
FIGURE 10-2 Canal incisions and tympanomeatal (TM) flap.

joint may be deceptive, so care must be taken not to enter the joint or, if its endosteum is entered, to cease drilling.

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