3.1.1 Arrangement of the Room

The operating room setup is shown in ▶Fig. 3.1, ▶Fig. 3.2, and ▶Fig. 3.3. The surgeon sits beside the bed on the side of the operated ear. The scrub nurse is located opposite side of the surgeon. The instrument table is located in front of the nurse. This position allows the nurse to deliver required instruments to both hands of the surgeon, and to offer required materials within the operative site without interfering with surgeon’s hands. In this way, the exchange between the nurse and the surgeon can be carried on without leaving a view under the microscope (▶Fig. 3.2). The microscope is positioned at the top of patient’s head to gain maximum adjustability. To enable these arrangements, position of the anesthesiologist should be away from the patient’s head, beside his legs. The intravenous infusion stand is placed in the same side, in front of the anesthesiologist. The scrub nurse controls the drill foot pedal, the bipolar and monopolar coagulator, and water irrigation. Each instrument is operated by the order of the surgeon vocally. In this way, the surgeon can concentrate on the operating field. A television monitor is placed where the scrub nurse can watch comfortably. The monitor will enhance recognition of the microsurgical process and allow appropriate assistance including choice of instruments, timing of switching, and flow rate of irrigating water.

3.1.2 Position of the Patient

The patient is placed in a supine position on the surgical bed that can tilt back and forth, and head down and up. The head of the patient is turned to the contralateral side. Usually, no pillows are used as far as the patient is comfortable. However, in obese patients and in patients with short neck, the chest of the patient sometimes disturbs movement of the surgeon’s elbow. This gives more trouble when the operated ear is on the same side as the surgeon’s favorite arm. A thin pillow is used in such cases, or in patients with cervical problems to set the proper position.

Because of complex three-dimensional anatomy, middle ear surgery requires frequent change of surgical angle between microscope and the operating field. On the other hand, under local anesthesia, the patient should recognize necessity of keeping his or her head still throughout the surgery, and frequent order to the patient to move his or her head is dangerous. The bed, rather than the microscope, is tilted toward any directions (▶Fig. 3.4). In that way, the surgeon can keep in an ergonomic and relaxed position that allows good work. For this purpose, the patient is tied to the bed at the wrists and thighs with safety belts. If control of structures located in the posterior mesotympanum is required, the bed is tilted toward the surgeon. For example, in ossiculoplasty in the second stage surgery, patients spend most of time in this position (▶Fig. 3.5). If the area of the anterior epitympanum or the eustachian tube should be controlled, the bed is tilted to the other side of the surgeon (▶Fig. 3.6).

In considerable time during surgery, the patient’s head is lowered. That position has an advantage in controlling the majority of the important structures such as the facial nerve, the oval window, the ossicular chain and the attic, which are located in superior half to the middle ear (▶Fig. 3.4). Since the position raises venous pressure of the operating field slightly, appropriate execution of hemostatic techniques need to be employed (see Chapter 4.1.3).

3.1.3 Preparation of the Operative Site

If a retroauricular incision is needed, the operative site is prepared by shaving the patient’s hair approximately two fingers from the attachment of the auricle (▶Fig. 3.7). In transcanal approach, no haircut is necessary. Adhesive tape is used to secure remaining hair (▶Fig. 3.8).

The local anesthetic solution is injected into the operative site in the way described below (see Chapter 3.2.1). Then, sterilization is performed by a solution containing 70% ethanol with 0.25% benzalkonium chloride (Citrosil, Glaxo, Italy). The patient is draped in layers using sterile cloths with adhesive tape. The last drape with a hole is placed in the center to expose the operative site (▶Fig. 3.9). Finally, an intensive lavage of the external auditory canal with Citrosil, 70% ethanol, and water is conducted.

3.1.4 Position of the Surgeon

The position of the surgeon is like a F1 pilot. The surgeon should stay in narrow area limited by the small operating field, but he or she should be placed as comfortable as possible to conduct precise manipulations for long time. The chair for the surgeon should have wheels to move freely with no impediment on the floor. Height of the chair should be adjustable. The surgeon should sit comfortably, well supported by a backrest that is draped. Distance between the surgeon and the operated ear should be within easy reach, making the operator’s elbows anatomically comfortable. This position allows the surgeon to keep meticulous concentration on operating field throughout the surgery. Surgeon’s legs are covered by the last drape to keep operating field clean and to hold instruments in case they slip down from the operating field. Right position (▶Fig. 3.10) and emphasized wrong position (▶Fig. 3.11) are shown.

3.1.5 Position of the Surgeon’s Hands

To maintain precise and fine manipulation throughout operation, position of the surgeon’s hands is of tremendous importance. The hands are placed on the patient’s head with one’s wrists straight, but not rigid, without obstructing surgical field. The surgeon’s arm of the operated side is placed on patient’s shoulder. Most of the instruments are held like a pen, but the superior aspect is not covered with fingers to obtain maximum view. Make sure that, especially near the delicate structures, a part of surgeon’s hand is supported by somewhere stable. This enhances precise manipulation without tremor, and in long operations, it avoids tension of the back, neck, and arms.

There are some differences in position of the hands, depending on approaches performed. Since retroauricular incision allows wide approach, surgeon can place his or her hands in more relaxed position with maximal support from the patient’s head and the body, keeping some distance between both wrists and hands (▶Fig. 3.12, ▶Fig. 3.13).

On the other hand, in transcanal and transmeatal approaches in which an ear speculum is used to establish access to the middle ear, the surgical angle is limited by the speculum. The distance between both hands is kept closer, and distance between the surface of the patient’s head and fingers holding instruments should be maintained larger to avoid blocking surgical view with the fingers. The middle finger of the favorite hand is placed on the edge of the ear speculum to obtain maximal support in such limited condition (▶Fig. 3.14, ▶Fig. 3.15).