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 fine 20-gauge needle suction in the left hand are used to elevate the soft tissue of the bony external ear canal. Care is taken not to tear the delicate skin of the medial portion of the ear canal skin. The tympanomastoid suture line and the tympanosquamous suture line are visualized. The surgeon then utilizes a No. 6400 Beaver
blade to make the superior and inferior incisions of the vascular strip, and a No. 7200 Beaver blade to make a parallel to annulus cut about 4 to 5 mm lateral to the annular rim. The vascular strip is then held anteriorly in the self-retaining retractor. This exposure now allows the surgeon to visualize the pathology of the tympanic membrane more clearly.
Now with the 20-gauge needle suction in the surgeon's left hand and a small round dissector in the right hand, the cuff of medial ear canal skin is elevated to the annulus. Generally a relaxing incision is made on the medial ear canal wall skin of the tympanic bone, 4 to 5 mm lateral and parallel to the inferior annulus. The middle ear is entered by elevating the cuff of skin until the fibrous annulus is visualized inferior to the chordae tympani nerve and then elevating the annulus inferiorly and anteriorly. At the point, the middle ear may be well visualized (Fig. 5—1).
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