Chapter 1
AN OVERVIEW OF MIDDLE EAR AND MASTOID SURGERY
Rex S. Haberman II
There are many indications for middle ear and mastoid surgery. Traumatic and nontraumatic perforations of the eardrum need repair, accomplished through a variety of ways. For a small defect, a myringoplasty or repair of the eardrum without lifting a tympanomeatal flap might suffice; for larger perforations, tympanoplasty becomes necessary. Techniques of tympanoplasty vary according to the size of the perforation and underlying disease. A transcanal approach may be all that is required, but frequently that does not give the surgeon sufficient exposure, so a postauricular approach becomes necessary. Medial and lateral grafting techniques all have their place, depending on the nature of the primary problem and training and preference of the surgeon. Both techniques have excellent results, as the take rate exceeds 90%.
Chronic otitis media with and without cholesteatoma is the major disease that leads the otologic surgeon to perform a mastoid operation. There are different approaches to mastoid surgery. Many believe that the logical approach to mastoidectomy is to leave the posterior ear canal intact and perform a canal-wall-up mastoidectomy. Others believe that leaving the posterior ear canal intact leaves the patient with too high a risk for recurrence of disease and that it is necessary to take the posterior canal wall down or perform a canal-wall-down mastoidectomy. There are modifications of those two basic mastoid surgeries, such as leaving the incus bridge intact, limiting the amount of bone removed, or even bypassing the mastoid completely if the disease is limited to the epitympanum.
In the middle ear, an assortment of conditions exist that call for surgical intervention. Erosion of the incus is a familiar condition that the ear surgeon encounters. There are many ossiculoplasty techniques that address that problem, including the insertion of various prostheses. Other ossicles may be involved in disease, either destroyed or fixed by fibrous tissue or tympanosclerosis, at times requiring complete replacement of the ossicular chain. Since the advent of stapedectomy almost 50 years ago, refinement of that technique has led to predictable and excellent results. There are many prostheses available to the general market, and most have led to the expected good result. Some new innovative prostheses are on the horizon, based on novel ideas regarding connection between the inner ear vestibule and incus.
Surgical treatment for Meniere’s disease and other vertiginous conditions, such as benign paroxysmal positional vertigo, typically involves performing mastoidectomy. At a minimum, simple mastoidectomy provides the basic entry to the labyrinth and endolymphatic sac. A thorough knowledge of the mastoid becomes a prerequisite for performing more complex temporal bone operations. From the mastoid, entry into the membranous labyrinth and internal auditory canal is possible, as is exposure of the posterior fossa dura, endolymphatic sac, and retrolabyrinthine area. Control of vertigo is the primary reason to perform inner ear surgery, although other symptoms such as hearing loss or tinnitus are often affected.
In the last few years, implantable hearing aids appeared, and implanting them may be a commonly performed procedure in the future. The technology continues to be refined, and as a result there is high expectation. Cochlear implants are relatively commonplace today. They have helped many patients who previously may have required sign language or lip reading. In the future, we can expect changes that could fulfill the desired objectives of otologists and otolaryngologists, that is, serving the needs of the hearing impaired to the greatest degree.
This book provides general otolaryngologists and residents of otolaryngology with a comprehensive presentation of the current status of middle ear and mastoid surgery. A chapter is assigned to each procedure, allowing easy reference to a specific operation in which the otolaryngologist may be interested. Each chapter describes in detail patient preparation and surgical technique. There is less focus placed on disease depiction, as other texts already provide that. After reviewing a chapter, the physician may then proceed to perform the selected surgery with added confidence and understanding of appropriate elements of the procedure.
PATIENT SELECTION AND INFORMED CONSENT
Virtually all patients who require middle ear or mastoid surgery have endured chronic symptoms. Patients with cholesteatoma typically present with purulent otorrhea that has plagued them for years. Otosclerotic patients often complain that their hearing has diminished gradually over many years. It is not uncommon for Meniere’s disease patients to have received treatment by a primary care physician for a long period before finally seeing the specialist, enduring many episodes of vertigo that may even have elicited trips to the emergency room. Thus, by the time the otolaryngologist sees the patients, expectations are high to find a cure and improve their lifestyle. Patients may exhibit unrealistic expectations about their condition and believe that a quick turnaround is imminent once treated by the otolaryngologist.
