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 is further exposed. Special care must be taken to prevent injury to the chorda tympani nerve posteriorly, the ossicles at the posterior superior quadrant, and the round window at the posterior inferior quadrant. The tympanomeatal flap is then laid anteriorly, leaving the attic widely exposed.
The integrity and the mobility of the ossicles are examined. Cholesteatoma is best removed en bloc to prevent recurrence. If ossicular erosion occurs, the
FIGURE 13 —4 A postauricular incision is placed at the auriculomastoid crease in a young adult. The facial nerve is protected by the mastoid tip, tympanic bone, and the fascia between the parotid and cartilaginous external canal.
decision of either a primary or staged ossicular reconstruction can be made based on the extent of the disease. Cholesteatoma at the attic and the sinus tympani can be removed using a Worlibur. To improve attic exposure, an atticotomy can be performed using a small bur or a curette. Irrigation water is placed in the middle ear and the mastoid. Free flow of water between the middle ear and the mastoid needs to be established to ensure adequate postoperative ventilation of the mastoid.
If a tympanoplasty is planned, the tympanic perforation is first postage-stamped and a rim of squamous tissue surrounding the perforation is removed with a cup forceps (this procedure is easier to perform before the tympanomeatal flap is elevated). The middle ear is packed with Gelfoam soaked with ofloxacin, or ciprofloxacin and hydrocortisone, to maintain the middle ear space. With the underlay technique, the previously harvested tem-poralis fascia graft can be placed under the tympa-nomeatal flap as far anterior to the perforation as possible. After the tympanomeatal flap is laid back onto the graft, a small amount of adjustment can be made through the perforation to ensure complete coverage of the perforation by the graft. Other options include lateral graft or a combination of the medial and the lateral technique.
If ossicular chain reconstruction is indicated, a primary or secondary operation can be carried out. The decision to delay ossicular reconstruction is often made on the basis of the severity of the disease encountered at the time of primary cholesteatoma removal. If the mucosa is edematous or is removed in a large amount, postoperative scarring and retraction are more likely to occur. Staging a reconstruction is more prudent. If a second exploration is planned, delaying the reconstruction is also appealing. If there is concern about eustachian tube dysfunction and postoperative aeration, it is often better to wait and see if an adequate middle ear space has developed and that the tympanic membrane has healed before the reconstruction. Our preference is to wait 18 months prior to reconstruction.
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