Hemostasis is a critical component of otologic and neurotologic surgery. In these surgeries the surgical field is small; thus, even a small amount of bleeding can obstruct the view of critical and extremely small structures. Additionally, relatively large vascular structures traverse the area; if they are encroached on by trauma or disease, bleeding must be controlled within a very small space in a meticulous fashion that does not encroach on structures of the middle ear and mastoid. The authors discuss several hemostatic agents in the middle ear, mastoid, and lateral skull base, highlighting their origins, mechanisms, advantages, and complications.
Key learning points
At the end of this article, the reader will:
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Understand the factors that make a hemostatic agent more ideal for use in different situations.
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Appreciate the patient factors that limit use of topical agents.
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Review the blood supply for paragangliomas of the middle ear and jugular foramen.
Introduction
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The combination of a small surgical field and very small critical structures increases the risk of injury due to poor visualization.
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Incomplete surgery due to poor visualization can easily occur.
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Postoperative bleeding can negatively impact
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Tympanic membrane graft take
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Positioning of middle ear prosthesis
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Brain function/brainstem position in the case of neurotologic procedures and may lead to emergent surgery to control bleeding
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Wound hematomas can lead to
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Postoperative discomfort
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Short term inability to wear glasses
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Wound infection
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Device removal may ultimately follow wound infection in the case of cochlear implants.
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Wound infection can lead to meningitis in neurotologic procedures.
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Introduction
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The combination of a small surgical field and very small critical structures increases the risk of injury due to poor visualization.
- •
Incomplete surgery due to poor visualization can easily occur.
- •
Postoperative bleeding can negatively impact
- ○
Tympanic membrane graft take
- ○
Positioning of middle ear prosthesis
- ○
Brain function/brainstem position in the case of neurotologic procedures and may lead to emergent surgery to control bleeding
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Wound hematomas can lead to
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Postoperative discomfort
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Short term inability to wear glasses
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Wound infection
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Device removal may ultimately follow wound infection in the case of cochlear implants.
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Wound infection can lead to meningitis in neurotologic procedures.
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Surgical strategies
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Initial injection of vasoconstrictive medications along incision line
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Cautery (monopolar and bipolar)
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High-speed otologic drill with diamond burr
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Topical use of vasoconstrictive medications
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Topical hemostatic agents
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Angiography and embolization
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Angiography and stenting (internal carotid)
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Arterial ligations of branches of the external carotid artery
For most otologic surgeries, the most critical component of hemostasis is the initial injection of diluted epinephrine into the ear canal and any planned postauricular or pinna incision sites. Subsequent control of bleeding for these procedures often involves cautery. Use of the otologic drill with an appropriately sized diamond burr and irrigation is an effective means of controlling bleeding from the mastoid bone ( Fig. 1 ). Topical agents should be used when cautery or drilling with a diamond burr would otherwise not be indicated, for example, when the bleeding process is adjacent to or on nerves or other delicate structures that would be damaged by heat transfer. Topical agents are also useful for control of bleeding in areas that are too small for introduction of the cautery.
Topical agents should be used cautiously in the sigmoid sinus and jugular bulb because of the potential for thrombosis. Careful use is also recommended in areas where excessive compression on nerves or other critical structures could occur. For otologic or neurotologic procedures involving vascular tumors, such as paragangliomas, preoperative angiography and embolization should be considered if possible. Emergent control of bleeding due to trauma or large tumors of the skull base may require embolization, stenting, or arterial ligation.
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Removal of disease
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Repair of hearing
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Minimization of morbidity
Removal of chronic infection or tumor is often the goal in otologic surgery for those conditions. However, a significant portion of otologic surgery is directed at improvement of hearing, particularly in the setting of otosclerosis or severe-profound sensorineural hearing loss. Control of bleeding particularly in these procedures is critical because morbidity resulting from damage to surrounding structures is unacceptable in elective hearing improvement surgery.
Options for hemostasis
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Source of bleeding
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Amount of bleeding
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Speed of hemostasis
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Risk of injury
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Impact on inflammation and healing
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Risk of infection
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Risk of systemic complications
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Origin
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Cost
The most critical factors to consider include the source and amount of bleeding. The use of certain agents can be inappropriate in some contexts and can cause severe morbidity. Another critical factor is the speed of hemostasis. Other factors to consider include impact on inflammation and healing, risk of infection, and risk of systemic complications in light of the patient comorbidities. Also important to consider are origin (plant, animal, human), cost, and available forms (sponge, fabric, powder, paste, and liquid).
Injection of vasoconstricting medications
Given the small size of the surgical field, a small amount bleeding from incision lines can obscure the field within seconds. Injectable vasoconstricting agents are used initially during otologic procedures to ensure adequate hemostasis from incision lines, particularly in the external auditory canal ( Fig. 2 ). Systemic complications are dose dependent.
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Types: diluted epinephrine; lidocaine + epinephrine
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Mechanism: vasoconstriction of blood vessels
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Advantages: inexpensive, can provide hemostasis throughout surgery if appropriately applied, lidocaine + epinephrine can also provide analgesia in addition to hemostasis
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Complications
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Lidocaine
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Systemic neurologic excitation followed by depression, convulsions, respiratory depression and arrest, bradycardia, hypotension, and cardiovascular collapse
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Temporary facial nerve paralysis if facial nerve is dehiscent in the middle ear (if applied in the external auditory canal or middle ear)
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Epinephrine
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Systemic effects: hypertension and tachycardia
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Local effects: tissue ischemia
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Cautery
Both monopolar and bipolar cautery are useful in controlling bleeding from small blood vessels of the scalp, pinna, and from scalp incision lines ( Fig. 3 ).
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Forms: bipolar and monopolar
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Bipolar cautery current passes through the tissues between the 2 electrodes of the instrument. Monopolar cautery current passes through patients to a grounding pad.
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Mechanism: (coagulation setting) Interrupted high-voltage current is dispersed over the surface, allowing superficial heating of tissue that causes protein denaturation and dehydration.
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Advantages: low cost, wide availability
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Complications
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Generation of areas of carbonization and necrotic tissue
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Increased likelihood of infection
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Delayed wound healing
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Generation of potentially toxic or infectious smoke that could potentially harm patients, surgeon, or operating staff
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