Fig. 2.1 The three variables for positioning of the head in ear microsurgery: rotation, tilt, and flexion–extension.

Fig. 2.2 Incorrect positioning with the head under rotated, extended, and tilted. This forces the surgeon to operate at an awkward angle, in the case depicted with the arm on the patient’s thorax.

Fig. 2.3 Optimal positioning with the head rotated, flexed, and not tilted.

Fig. 2.4 When the patient is positioned well, the surgeon should be able to gaze from the epitympanum to hypotympanum. Suboptimal patient positioning contributes to neck and lower back problems endemic among otologic surgeons.

Fig. 2.5 Downwardly deflecting the opposite shoulder helps achieve rotation and flexion needed for optimal positioning.

Fig. 2.6 Correct position has head rotated and head flexed with opposite shoulder deflected downward.

Fig. 2.7 When the opposite shoulder is not pushed down, the head tends to be under-rotated and the neck extended.

Fig. 2.8 In most ear microsurgery, the head is rotated and flexed, but with the head neutral neither tilted up nor down.

Fig. 2.9 In a child, the head is proportionally larger than the body. This leads to a flexed position.

Fig. 2.10 Towels placed under the back can achieve a neutral position.

Fig. 2.11 In a barrel-chested adult, the body is proportionally larger than the head.

Fig. 2.12 Towels placed under the head can achieve a neutral position.

Fig. 2.13 Table positioning for stapes surgery to optimally view the posterior superior quadrant of the middle ear. This is the starting point.

Fig. 2.14 Table positioning for stapes surgery: slight Trendelenburg (head down).

Fig. 2.15 Table positioning for stapes surgery: slight rotation toward the surgeon to optimize angle to the posterior–superior quadrant.

Fig. 2.16 Last step in table positioning for stapes surgery is raising the bed to allow microsurgery at a comfortable height for the surgeon.

Fig. 2.17 Incorrect hand position for ear microsurgery, which is less stable and limits visibility. The correct hand position has three-point stabilization.

Fig. 2.18 Correct hand position enables both greater stability and two eyed visualization.

Fig. 2.19 Correct arm and hand position has multiple points of stabilization. Without stabilization of the forearm and wrist (“operating from the elbow”), maintaining steady control of the tip of a microsurgical instrument is very difficult.

Fig. 2.20 Placement of the surgeon’s hands during transcanal microsurgery. The third and fourth fingers of each hand stabilize the speculum. Note that the microinstrument (right hand) and suction (left hand) are held in a manner to both optimize stability and to enable binocular viewing. Some surgeons use a speculum holder to enhance stability, but it is best for all ear surgeons to be trained without use of a holder as such devices may not be available in all settings.

Fig. 2.21 The proper holding of a drill enables binocular visualization.

Fig. 2.22 Note that gripping the drill at two points is more stable and also improves visibility down the shaft.

Fig. 2.23 Gripping the drill too far up the shaft reduces control of the burr.

Fig. 2.24 A sizable fraction of ear microsurgeons develop back problems over time. This can be mitigated by using proper posture during microsurgery. This involves upright posture and good lumbar support as shown here. Many surgeons use rests to enhance stability and alleviate arm fatigue.

Fig. 2.25 Forward leaning posture lacking in lumbar support puts stress on the lower back.

Fig. 2.26 Some otologists were taught to practice the “otological slouch” because theoretically it was a relaxed posture. However, a curved back, rounded shoulders, and a flexed neck is ergonomically unsound and contributes to low back problems.