13.1 Bleeding from the Dura

Bleeding from the dura is managed by bipolar coagulation with minimal power. Monopolar coagulation is prohibited since it may create a hole on the dura. If troublesome bleeding occurred between the bony shell and the dura, Surgicel is inserted under the bone. The Surgicel may be left in place at the end of the surgery. The exposed dura may be covered with the temporalis fascia.

13.2 Bleeding from the Sigmoid and Other Sinuses

If the sinus is covered with bone, drilling with a large diamond burr is tried. If the bleeding does not stop, bipolar coagulation may be applied. Again, do not use monopolar coagulator to avoid further damaging the sinus. If bleeding sustains, Surgicel is placed on the tear and pressure is applied over it by placing cottonoids. Leaving this material in place eventually stops bleeding. After removing the Surgicel, bipolar coagulation is applied to ensure closure of the tear, or the Surgicel may be left in place. The sigmoid sinus exposed in the open cavity is covered with bone paté and fibrin glue, and the temporalis fascia is placed. Bleeding from the superior and the inferior petrosal sinuses may be managed by packing the sinus with Surgicel.

13.3 Bleeding from the Jugular Bulb

If the high jugular bulb is exposed in the hypotympanum without bony coverage and the situation is not recognized, the surgeon may tear its wall during some maneuvers such as elevation of the fibrous annulus.

In transcanal approaches, the tympanic cavity is tightly packed with sufficiently large Surgicel to avoid pulmonary embolization. Massive bleeding from the tympanic cavity usually forces surgeon to give up any further manipulation to the middle ear. The tympanomeatal flap is replaced, and the external auditory canal is tightly packed with Gelfoam in such cases.

In retroauricular transmastoid approaches, the area of bleeding is first packed with large pieces of surgical. After placing pieces of cottonoid over that area to ensure tight packing, operation can be continued in other areas. Leaving these materials usually stops bleeding. After achieving complete hemostasis, the cottonoids are gently removed to complete the surgery. The Surgicel is left in place and the skin is closed.

13.4 CSF Leak

Cerebrospinal fluid (CSF) leak into the middle ear may occur when the dura is insulted during removal of middle ear pathology and drilling the bone, usually with cutting burrs. In cases with bony defect such as large cholesteatoma and revision surgery, the dura may protrude into the middle ear, and may be easy to damage if care is not taken. The dura becomes thin and fragile, especially in the area of the middle fossa of elderly patients.

The CSF leak may be classified into two situations. (1) If the arachnoid membrane is not insulted, the leak may be small and easily stopped. A small dural opening can be repaired by a small piece of either periosteum or muscle inserted into the tear. The piece is fixed with fibrin glue. Larger openings are closed by a piece of muscle or periosteum and sutured to the dura. Bony defects are repaired by inserting a sufficiently large piece of cartilage (either autologous or homologous) beneath the bone. The defect is further covered with a sufficiently wide fascia fixed with fibrin glue. (2) If the arachnoid membrane is insulted, more CSF flows out from the subarachnoid space, and risk of postoperative CSF leak followed by meningitis may be higher with usual treatment. In such cases, radical mastoidectomy, closure of the eustachian tube, obliteration of the cavity with abdominal fat, and blind-sac closure of the external auditory canal are employed (see Chapter 11).

Postoperatively, absence of sustained leakage should be checked by asking the patients whether there is any rhinorrhea or postnasal drip especially in recumbent position. Tilting the head forward in sitting position may reveal some serous fluid coming out from the eustachian tube. If CSF leak sustains postoperatively, spinal drainage is introduced and the patient is carefully observed for a few days. If the leak lasts more, revision surgery is indicated.

13.5 Labyrinthine Fistula

Opening of the labyrinth may occur during drilling or dissection of pathologic tissue from bony structures in the area of the labyrinth (see Chapter 10). If the fenestration of the labyrinth is recognized immediately after it happens, bone wax may be applied as soon as possible to obliterate the opening. The other option is to use small piece of fascia to cover it and fibrin glue is applied for fixation. The area is further covered by a large fascia in the end of operation. If labyrinthine fistula is suspected but not sure, useful technique is to push the stapes gently with a small hook. Any movement of that area under microscope indicates presence of a fistula. Fenestration sometimes occurs anteriorly in the lateral semicircular canal, close to the ampulla. In such cases, even after immediate closure, postoperative sensorineural hearing loss may follow.

13.6 Disarticulation of the Incus

Excessive force on the incus during manipulation of pathologies around the ossicular chain or inadvertent drilling near the short process of the incus may cause disarticulation of this ossicle. Unawareness and/or leaving this status may result in postoperative uncoupling of the tympanic membrane and the stapes. The disarticulation easily occurs when the incudomalleal joint is eroded. Removal of the incus after complete disarticulation of the incudostapedial joint is required in such cases. Ossiculoplasty is performed in either the same or the second stage, depending on the status of the pathology.