Mastoid and Middle Ear Surgery

and Yue-shuai Song6



(5)
Department of Otolarygngology Head and Neck Surgery, PLA General Hospital, Beijing, 100853, China

(6)
Department of Otolarygngology Head & Neck Surgery, Beijing Friendship Hospital,, Capital Medical University,, Beijing, 100050, China

 



Indications





  1. 1.


    Refractory secretory otitis media, without improvement after conservative treatments, such as antibiotics, Eustachian tube inflation or previous tympanostomy alone.

     

  2. 2.


    Glue ear or severe atelectasis.

     

  3. 3.


    Severe conductive hearing loss due to negative middle ear pressure and having an effect on language development.

     

  4. 4.


    Recurrent acute otitis media.

     

  5. 5.


    Abnormal patency of Eustachian tube.

     

  6. 6.


    Hyperbaric oxygen therapy.

     


Contraindications


Systemic conditions with patient not suitable for local or general anesthesia.


Operative Procedures





  1. 1.


    Remove cerumen, then sterilize EAC with 0.1 % thimerosal solution.

     

  2. 2.


    Tympanic membrane is incised full-thickness under the operating microscope. The length of the incision is about 2–4 mm, and should match the diameter of the inner flange of ventilating tube. Considering manubrium of malleus as vertical axis, umbo of tympanic membrane as horizontal axis, tympanic membrane can be divided into four quadrants, anterior-superior, anterior-inferior, posterior-superior and posterior-inferior. The incision is usually located in the anterior-inferior quadrant of the membrane for better drainage.

     

  3. 3.


    Drainage of middle ear fluid, and lavage the cavity with the mixed solution of dexamethasone and α chymotrypsin.

     

  4. 4.


    Tympanostomy tube in position.

     


Special Comments





  1. 1.


    It is necessary to inspect the tympanic membrane under the microscope preoperatively. A blue or red color of the membrane may indicate a high jugular bulb (more common on right side) or glomus tumor. One should also look for pulsation behind the tympanic membrane.

     

  2. 2.


    It is better to use a ventilating tube made of Teflon for less infection and less occlusion. Caution: a silicone tube may result in the formation of granulation tissue after prolonged intubation. Shepard and Armstrong Grommets are suitable for most cases, while Goode T Grommet have an increased risk of residual tympanic membrane perforation after long term use ventilation.

     

  3. 3.


    The incision should avoid the posteriorsuperior quadrant of the drum in order to protect the ossicular chain. In case of long-term intubation, it is better to place the incision in front of the malleus handle.

     

  4. 4.


    The incision should not be too close to the tympanic annulus or umbo of tympanic membrane for most stable placement.

     

  5. 5.


    The incision should be made and the drainage tube should be placed in a healthy segment of the tympanic membrane.

     

  6. 6.


    The EAC should be kept dry. The ear should be reviewed regularly. Avoid any kind of fluid, and apply antibiotic ear drops for infection or apply heparin if the tube is occluded.

     


Complications





  1. 1.


    Injury of ossicular chain: this is uncommon if the ventilating tube is placed in the antero-inferior quadrant under operating microscope.

     

  2. 2.


    Otorrhea after tympanostomy tube placement: Avoid infection by sterilizing the operating field carefully and lavaging the external canal with a solution containing antibiotics and glucocorticoid. Otorrhea may occur in some children despite these measures. If otorrhea occurs, apply antibiotic ear drops. Refractory otorrhea requires regular cleaning of the external canal and aspiration of middle ear fluid.

     

  3. 3.


    A residual perforation following tube removal may take 1 or 2 years to fully heal spontaneously.

     

  4. 4.


    Tube displaced into the tympanic cavity: this may be caused by an oversized incision or drum atrophy. If this occurs, the tube may be removed via the original or an extended incision.

     

  5. 5.


    Bleeding from high jugular bulb: A high bulb appears as a dark red structure beneath the tympanic membrane and should be identified before tympanostomy, to avoid injury. If bleeding occurs, stop the operation immediately and pack the canal with gelfoam and antibiotic gauze for hemostasis.

     


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Fig. 2.1
Exposure of tympanic membrane

Remove cerumen from the external canal, sterilize the operation field with 0.1 % thimerosal solution. Expand external canal by otoscope or nasoscope, expose tympanic membrane under operating microscope. The tympanic membrane has lost it’s normal gloss and appears yellow. A dilated capillary can be seen on the pars tensa, and the tympanic cavity contains fluid


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Fig. 2.2
Myringotomy

The myringotomy is carried out with a myringotomy knife in the anteroinferior quadrant of the drum, remaining 3 mm away from the tympanic annulus. The length of the incision should match the diameter of the inner flange of the ventilating tube. In cases of atelectasis, the myringotomy should be made over the deepest possible region of the hypotympanum


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Fig. 2.3
Drainage of middle ear effusion

After the effusion is aspirated using the smallest possible suction tubes, the inner wall of tympanic cavity is exposed. If the secretion is viscous, an adjuvant incision may be performed at the posteroinferior quadrant to aid aspiration


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Fig. 2.4
Tympanic cavity irrigation

Irrigate and aspirate the tympanic cavity with a mixed solution of dexamethasone and α chymotrypsin gently and repeatedly


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Fig. 2.5
Placement of the ventilating tube

A ventilating tube is introduced into the external auditory canal carefully with a specialized tympanic cavity tubing pusher. One side of the tube is inserted into the incision first, then it is rotated into the tympanic cavity. Finally, adjust the position of the ventilating tube with a 1.5 mm, 45° hook


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Fig. 2.6
Check the position of the ventilating tube

After the placement of the ventilating tube, its position and stability should be checked. In this case, there is some clear liquid in the tube lumen, the length of the incision is appropriate, and the tube is correctly positioned


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Fig. 2.7
Adjust the position of the ventilating tube

Aspirate blood and liquid from around the ventilating tube, and adjust the position of the tube if necessary. If the tube is displaced into the tympanic cavity, grasp the blue strap on the tube and remove it using a large straight alligator forceps, then reposition the tube correctly



Myringoplasty



Rui-li Yu and Yue-shuai Song7


(7)
Department of Otolarygngology Head and Neck Surgery, PLA General Hospital, Beijing, 100853, China

 


Indications





  1. 1.


    The conducting function of ossicular chain is normal.

     

  2. 2.


    The size of the perforation is medium or large

     

  3. 3.


    Small perforation but the residual drum is atrophic

     

  4. 4.


    The edges of the perforation are infolded.

     

  5. 5.


    Persisting perforation despite cautery and application of ointment

     

  6. 6.


    The ossicular chain should be evaluated when a pre-operative patch test fails to improve hearing.

     


Contraindications





  1. 1.


    Middle ear cholesteatoma.

     

  2. 2.


    Acute suppurative otitis media.

     

  3. 3.


    Acute infection or active chronic suppurative otitis media.

     

  4. 4.


    Ear Pseudomonas aeruginosa infection disease in diabetes mellitus patients.

     

  5. 5.


    Patient unfit for surgery.

     


Operative Procedures





  1. 1.


    Anesthesia: General or local anesthesia is used in adults, and general anesthesia is used in children. The local anesthesia is injected in four quadrants just lateral to the bone external canal and 2 % tetracaine solution is instilled in the tympanic cavity for surface anesthesia during surgery.

     

  2. 2.


    The preparation of the graft: the temporalis fascia is harvested from the side of the affected ear. A horizontal incision approximately 2.5 cm long is made, 2–3 cm above the auricle. After separating the subcutaneous tissue, the tough white fascia close to the temporal muscle is exposed. The fascia is separated from the underlying muscle. The graft has a diameter of 1.5–2 cm. The graft is spread on a block and any excess fat and muscle are removed. The fascia is placed in the 75 % alcohol until it is used.

     

  3. 3.


    The first skin incision starts from the 12 o’clock position of EAC and carried down to the bone. It is extended laterally between the tragus and the crus of helix for about 1.0 cm.

     

  4. 4.


    The second incision is semi-circumferential and performed just medial to the bony-cartilaginous junction. It starts from the 6 o’clock position of EAC, and remains 5 mm lateral to the tympanic annulus along the posterior meatal wall in an ascending spiral fashion to meet the first incision. The edges of the perforation are freshened with a straight needle before the tympanomeatal flap is elevated.

     

  5. 5.


    Elevation of meatal skin flap: An articulated retractor is introduced to expose the operating field. The skin and periosteum of EAC are separated from the underlying bone to the level of the tympanic annulus. The overhanging suprameatal spine is removed using a diamond burr or osteotome.

     

  6. 6.


    The epithelial layer of the tympanic membrane remnant is separated from the fibrous layer, superiorly, anteriorly and inferiorly in sequence. This prepares the bed for the total overlay grafting technique. However if one edge of the perforation is close to the tympanic annulus, the tympanomeatal flap is raised lifting the annulus to enter tympanic cavity for the combined underlay grafting technique.

     

  7. 7.


    In the combined underlay grafting procedure, one should inspect the tympanic cavity and ossicular chain after the tympanomeatal flap is elevated when an ossicular problem is suspected. Care should be taken to protect the chorda tympani nerve when separating the fibrous tympanic annulus.

     

  8. 8.


    The long process of the incus and the incudostapedial joint are exposed with removal of some bone from the postero-superior canal wall.

     

  9. 9.


    After aspiration of blood, the condition of the tympanic cavity and the mobility of the ossicular chain are examined. Any infected material is removed. Gelfoam pledgets soaked in antibiotic solution are placed in the tympanic cavity.

     

  10. 10.


    The temporalis fascia is introduced between the epithelial and the fibrous layer of the tympanic membrane remnant (for the total overlay grafting technique); or placed between the tympanomeatal flap and the bony canal wall. If there is little or no anterior tympanic membrane remnant, the graft is inserted against the anterior wall of the tympanic cavity and pledgets of gelfoam are placed in the middle ear to support it. The graft is placed lateral to the malleus handle.

     

  11. 11.


    Repositioning the meatal skin flap: the meatal skin flap and tympanic membrane remnant are replaced in their original position, covering the fascia. The graft should not extend beyond the external canal incision. The fascia is adjusted to cover the perforation.

     

  12. 12.


    The external canal is packed with gelfoam and a strip of iodoform gauze.

     

  13. 13.


    Incision closure.

     


Special Comments





  1. 1.


    The condition of the middle ear should be explored in cases with a marginal perforation.

     

  2. 2.


    The epithelial layer of the drum must be preserved during its elevation. If this is not achieved, the combined underlay grafting technique will be used.

     

  3. 3.


    Removal of epithelial remnants: after the tympanomeatal flap is elevated, care must be taken to remove any residual epithelial remnants on the surface of the fibrous layer of the tympanic membrane to prevent inclusion under the graft.

     

  4. 4.


    Protection of the chorda tympani nerve: The chorda tympani nerve should be preserved while elevating the posterior tympanomeatal flap and separating the tympanic annulus. The nerve is identified as a cord-like structure along the tympanic sulcus. It should be carefully dissected free from the sulcus and the bone.

     

  5. 5.


    Care should be taken not to damage the ossicular chain.

     

  6. 6.


    Ensure that the graft covers the perforation completely. Gentle even pressure should be used when filling the external canal with the gelfoam and gauze.

     


Complications





  1. 1.


    Incomplete closure of the perforation: this complication may result from the inadequate separation of the epithelial layer from the fibrous layer of the tympanic membrane remnant. The local anesthetic should be injected deep to the epithelial layer to make the separation easier. One must ensure a strict intraoperative aseptic technique. The ear canal packing should be removed within 2 weeks of surgery.

     

  2. 2.


    Formation of Cholesteatoma deep to the repaired tympanic membrane: this complication occurs when remnants of epidermis have been left on the margin of perforation. The growth of these remnants leads to the formation of the new cholesteatoma lateral to the fibrous layer of the tympanic membrane.

     

  3. 3.


    Retraction pocket: this complication results from the inadequate Eustachian tube function or tympanic membrane adhering to the medial wall of the middle ear. This complication can be avoided by placing gelfoam pledgets soaked in the antibiotic solution in the tympanic cavity.

     

  4. 4.


    Thick tympanic membrane: this complication occurs if the graft is too thick. Excess fat and muscle tissue must be removed from the fascia prior to its insertion.

     

  5. 5.


    Blunting of the anterior tympanomeatal angle: This can occur due to the inadequate fixation of the anteroinferior graft by gelfoam pledgets.

    Incomplete fusion of the drum to the manubrium of malleus: this complication is often seen in the total overlay grafting procedure, and occurs when the graft shrinks and becomes detached from the malleus handle.

     

  6. 6.


    Stenosis of the external auditory canal: this complication can occur due to extensive injury to the canal skin, postoperative infection and proliferation of granulation tissue.

     

Surgery 1: Myringoplasty

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Fig. 2.8
Endaural incision

The fascia is harvested from the temporal muscle above the affected ear and dried in 75 % ethanol. The first skin incision is made at the 12 o’clock position of EAC just lateral to the bony-cartilaginous junction and carried down to the bone. An outward prolongation of about 1.0 cm in length is made between the tragus and the crus of helix, and then under the operating microscope the first incision is extended inward to a point about 0.8–1.0 cm lateral to the tympanic annulus. The second incision starts from the 6 o’clock position of EAC, and remains 5 mm lateral to the tympanic annulus along the posterior meatal wall in an ascending spiral (or curved) fashion to meet the first incision. The soft tissue in the junction of these two incisions often needs to be cut with a sharp knife


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Fig. 2.9
Elevation of the meatal skin flap and the epithelial layer of the posterior tympanic membrane

Remove the overhanging suprameatal spine using a diamond burr or chisel. Separate the skin of EAC to the level of the tympanic annulus and elevate the epithelial layer of the remnant tympanic membrane across the tympanic sulcus. Expose the lateral process of malleus by separating the epithelial layer from the fibrous layer covering this process


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Fig. 2.10
Separate the epithelial layer from the inferior remnant of tympanic membrane

Separate the epithelial layer from the fibrous layer of the tympanic membrane postero-inferiorly, inferiorly and antero-inferiorly, respectively. Then, the epithelial layer is separated from the fibrous layer totally and the tympanomeatal flaps are elevated anteriorly like a swinging door


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Fig. 2.11
Elevation of the tympanomeatal flaps

After the meatal portion and the tympanic portion of the flap are raised totally, the tympanomeatal flap is completed. Preserve the pedicle including the skin of the anterior wall of the external canal. This will prepare the bed to accept the graft. A posterosuperior tympanomeatal flap is raised, exposing the full-view of the fibrous layer and perforation edges, including the calcified plaque in the fibrous layer of the tympanic membrane in this case


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Fig. 2.12
Removal of calcified plaque in the fibrous layer of the tympanic membrane

Pierce around the margin of the calcified plaque in the tympanic membrane remnant and remove the plaque intact


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Fig. 2.13
Expose the manubrium of malleus after removing the calcified plaque

Remove the calcified plaque in front of the manubrium of the malleus to expose it completely. Care should be taken to avoid altering the position of the normal fibrous layer


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Fig. 2.14
Inspecting the incudostapedial joint

After removing the sclerosis of the fibrous layer, the incudostapedial joint is exposed. The mobility and integrity of the ossicular chain is tested and no abnormality was found in this case


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Fig. 2.15
Introduction of the temporal fascia

The graft is cut with scissors to the appropriate size to cover the perforation. The graft is introduced between the tympanomeatal flaps and the fibrous layer of the tympanic membrane. Care should be taken to ensure that the posterior edge of the graft does not protrude posterior to the line of the second incision. The fascia should be placed flat, without folds, bulges or indentations


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Fig. 2.16
Repositioning the meatal skin flap and the epithelial layer of the drum

The tympanomeatal flaps are repositioned, keeping the fascia in contact with the tympanic annulus and between the epithelial layer and fibrous layer of the drum


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Fig. 2.17
Placing the gelfoam on the surface of the drum

Gelfoam pledgets soaked in antibiotic solution are placed in the external acoustic meatus, on the lateral surface of the tympanic membrane and covering the second incision


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Fig. 2.18
Packing the external meatus with a strip of iodoform gauze and closing the wound

The external canal is packed with 0.5–1.0 cm strip of iodoform gauze, and the incision is closed

Surgery 2: Myringoplasty

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Fig. 2.19
Endaural incision

The fascia is harvested from the temporal muscle above the affected ear and is dried in 75 % ethanol. The skin incision is made between the tragus and the crus of helix and an inward extension is made to a point about 0.8–1.0 cm lateral to the tympanic annulus. The second incision starts from the 6 o’clock position of EAC, and remains 5 mm lateral to the tympanic annulus along the posterior meatal wall in an ascending spiral fashion to meet the inner part of the first incision


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Fig. 2.20
Excising the perforation margins

The edges of the perforation are freshened with a hooked needle 3 mm away from its margin. Care must be taken to remove all epithelial remnants from the rim of the perforation


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Fig. 2.21
Separate the posterior epithelial layer of the tympanic membrane

Remove the overhanging suprameatal spine using a sharp diamond burr or chisel. Separate the meatal skin flap as far as the tympanic annulus and elevate the epithelial layer from the posterior remnant of the tympanic membrane across the tympanic sulcus. Then separate the epithelial layer from the fibrous layer of the tympanic membrane anteriorly to the manubrium of malleus


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Fig. 2.22
Separate the epithelial layer from the anterior part of tympanic membrane

The epithelial layer is separated from the fibrous layer, then the edges of the tympanic membrane perforation are excised


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Fig. 2.23
Remove the calcified plaque

Remove a calcified plaque in the fibrous layer posterior to the malleus


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Fig. 2.24
Repositioning the epithelial layer of the tympanic membrane

The transplant bed of tympanic membrane is created, and the epithelial layer of the tympanic membrane is repositioned. Inspect the edges of the perforation again


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Fig. 2.25
Check the extent of separation of two layers of the tympanic membrane

Use micro spatula to check separation of the epithelial layer and fibrous layer of the tympanic membrane remnant


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Fig. 2.26
Inspecting the tympanic cavity

The postero-superior part of fibrous annulus is raised from the tympanic sulcus, and the excess bone of the posterosuperior meatus is removed. The tympanic cavity and part of ossicular chain are visible. Pierce around the edge of the calcified plaque in the tympanic membrane remnant successively and remove the calcified plaque. Take care to preserve the normal fibrous layer as much as possible


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Fig. 2.27
Exposure of the chorda tympani nerve

The chorda tympani nerve is identified between the manubrium of malleus and the long process of the incus, along the line of the tympanic sulcus.Take care to separate the nerve along the tympanic sulcus to protect it from injury


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Fig. 2.28
Checking the auditory ossicles

After the excess bony overhang of the posterosuperior meatal wall is removed, the integrity of the incudostapedial joint and the mobility of the ossicular chain are tested (or inspected). They are both normal in this case


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Fig. 2.29
Introducing the temporal fascia graft

The graft is introduced between the fibrous layer of the tympanic membrane and the epithelial tympanomeatal flap


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Fig. 2.30
Repositioning the tympanic membrane

The tympanic membrane is placed in its original position. Care is taken to ensure the temporal fascia graft fully covers the perforation


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Fig. 2.31
Packing the ear canal

Placing the gelfoam on the surface of the drum, packing the external canal with a strip of iodoform gauze, and closing the incision


Tympanoplasty



Yi Sun and Yue-shuai Song9


(8)
Department of Otolaryngology, Chinese PLA Wuhan General Hospital, Wuhan, 100853, China

(9)
Department of Otolarygngology Head and Neck Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China

 


Indications





  1. 1.


    Tympanoplasty can be used in Chronic otitis media and mastoiditis patients (including cholesteatoma), but only when middle ear infection is controlled, the Eustachian tube is not obstructed and there is good cochlear function.

     

  2. 2.


    Traumatic ossicular chain discontinuity

     

  3. 3.


    Congenital middle ear malformation

     

  4. 4.


    Ossicular erosion or fixation or tympanosclerosis from chronic otitis media

     


Contraindications





  1. 1.


    Poor cochlear function

     

  2. 2.


    Malignancy of the middle or external ear (combined with radiation therapy)

     

  3. 3.


    Pseudomonal infection in diabetic patients

     

  4. 4.


    Otogenic intracranial complications

     

  5. 5.


    Patient unfit for surgery

     


Operative Procedures





  1. 1.


    Anesthesia: Local anesthesia can be used in adults. General anesthesia is used for children. Local anesthetic solution is injected into the skin of the wall of the external auditory canal. Cotton wool soaked with 2 % decicaine is placed on the surface of the tympanic membrane around the perforation for additional surface anesthesia.

     

  2. 2.


    Graft preparation: Temporalis fascia is harvested. A 2.5 cm long horizontal skin incision is made parallel to the hairline at the top of ear. After division of the subcutaneous tissue the white and tough fascia can be identified over the temporalis muscle. A circular fascial graft of 1.5–2.0 cm in diameter is taken. The graft is cleaned of muscle and loose connective tissue. It is placed in 75 % alcohol solution until use.

     

  3. 3.


    The first incision: A longitudinal incision is made at the top of EAC, with a 1.0 cm lateral extension along anterior border of crus of helix.

     

  4. 4.


    The second incision: Make a semicircular incision at bony part of auditory canal, which extends from 6 o’clock up to the inner end of first incision along the posterior wall 0.5 cm away from the tympanic annulus.

     

  5. 5.


    Elevation of the EAC skin flaps: Elevate the skin and periosteum of EAC towards the tympanic annulus. Curette away the spine of Henle if is prominent.

     

  6. 6.


    The epithelial layer of the tympanic membrane is separated from the fibrous layer in an anterior direction to form the bed for the graft in the inlay technique.

    The drum remnant is elevated as one layer in the underlay technique.

     

  7. 7.


    Once the tympanomeatal flap is prepared for the inlay technique, if exploration of the middle ear and ossicular chain is needed, the tympanic annulus can be elevated from the postero-superior part of the tympanic sulcus (right side from 9 to 12 o’clock position, left side from 12 to 3 o’clock position), whilst paying attention to protect the chorda tympani nerve.

     

  8. 8.


    Part of the postero-superior wall of the external auditory canal can be removed with a curette or chisel to expose the long process of the incus and the incudostapedial joint.

     

  9. 9.


    After entering the tympanic cavity, blood and any debris is suctioned to allow inspection of the ossicular chain and clearance of any disease associated with it.

     

  10. 10.


    Placement of temporalis fascia: the fascia is inserted between the outer epithelial layer and fibrous inner layer of the tympanic membrane (inlay technique), or inserted under the drum and between the tympanomeatal flap and auditory canal bony wall. If there is no residual rim of the tympanic membrane anteriorly, the fascia is placed right to the anterior wall of the middle ear and a small extension is placed over the annulus to anchor the graft. The anterior and inferior middle ear space is well packed with gelfoam to ensure it stays in contact with the under surface of the drum remnant.

     

  11. 11.


    If ossicular chain reconstruction is needed, the temporalis fascial graft is reflected forward with the tympanic membrane remnant to expose the middle ear space. Suitable materials and methods for reconstruction are selected depending on the status of ossicular chain.

     

  12. 12.


    Repositioning the EAC skin flap: Replace the tympanomeatal flap with the graft that has been inserted. Ensure that the graft covers the perforation and does not extend laterally beyond the edge of the skin flap.

     

  13. 13.


    Fill the EAC with gelatin sponge and then iodoform gauze.

     

  14. 14.


    Suture the incision.

     


Special Comments





  1. 1.


    Inject local anesthetic solution under the skin to cause blanching but avoid excessive swelling, bruising or disruption of the canal skin.

     

  2. 2.


    Carefully dissect the tympanic membrane and handle of malleus, to avoid injury. The incudostapedial joint can be separated temporarily if necessary to prevent injury to the inner ear with consequent tinnitus, or even irreversible sensorineural hearing loss.

     

  3. 3.


    Ensure the gelfoam placed in the middle ear is only lightly moistened with normal saline

     

  4. 4.


    If an autograft incus is used to reconstruct the ossicular chain, ensure that it is healthy and does not contain cholesteatoma.

     

  5. 5.


    Make sure the attic lateral wall is intact at the end of the procedure, with any defect repaired

     


Complications





  1. 1.


    Perforation of ear drum: this may happen if the fascial graft is too small and does not cover the perforation completely, or if it is too large and does not lie correctly to make good contact with the recipient bed and develop a good blood supply.

     

  2. 2.


    Lateral healing of the tympanic membrane: this is mostly caused by inappropriate graft placement and packing, either by excessive separation of anterior edge skin of the recipient bed or loss of and blunting of the acute angle between the tympanic membrane and the anterior EAC wall.

     

  3. 3.


    Cholesteatoma: a small cholesteatoma or epidermoid can be seen frequently on the surface of tympanic membrane, or on the EAC recipient bed due to implantation of squamous epithelium. When this occurs, it can be removed simply in the clinic without harmful effects. This should be done early to avoid ingrowth of Cholesteatoma to the middle ear.

     

  4. 4.


    Inner ear injury: dissection of disease or tympanosclerosis from the ossicular chain may cause inner ear damage if it is not done delicately. The stapes can even be dislocated, leading to inner ear injury and creating a pathway for infection to spread to the inner ear. Inner ear damage is seen more frequently in the aged and those with poor inner ear function.

     

  5. 5.


    EAC stenosis: excessive trauma to the skin of the EAC, infection and proliferation of granulation can cause EAC stenosis.

    Widening of the bony ear canal and repair of any areas skin loss with full-thick skin grafts will help prevent this.

     

  6. 6.


    Tympanic membrane retraction pocket: when extensive removal of the postero-superior bony canal wall is required, a retraction pocket can occur even in the presence of normal Eustachian tube function. Bone defects in this area should be repaired with a cartilage composite graft to prevent formation of a retraction pocket which may progress to cholesteatoma.

     

  7. 7.


    Facial palsy: facial nerve damage mostly occurs at the second genu, in the postero-superior region of the tympanic cavity, where dissection may be blind and the bony facial nerve canal is likely to be deficient leaving the nerve exposed and possibly herniating.

    Chemicals (such as acetaldehyde and peroxyacetic acid) contained in the gelatin sponge used to pack the tympanic cavity may cause facial nerve protein denaturation.

     

Surgery 1: Tympanoplasty, ossiculoplasty

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Fig. 2.32
Endaural incision

A longitudinal incision is made at the top of EAC, and extended about 1.0 cm along anterior border of the crus of helix. The inner end of the incision stops 0.8–1.0 cm lateral to the pars flaccida of the tympanic membrane. The second incision is circumferential and made 0.5 cm behind the tympanic annulus. It extends from the 6 o’clock position, over the posterior EAC wall to meet the inner end of the first incision


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Fig. 2.33
Elevation of EAC Skin flap

The skin and periosteum of the EAC is elevated from the second incision inwards to the tympanic annulus. The dissection is carried out over a broad front avoid too much elevation in one area alone. The dissector is kept tightly on the bone and a fine bore sucker is used to avoid trauma to the flap which is often quite thin


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Fig. 2.34
Elevation of superior EAC skin flap

The posterior and inferior skin flap of the EAC is elevated, then the superior skin flap is reflected to the anterior wall. The anterior superior spine of bone is exposed and removed if it is too prominent.

This picture shows the bony part of superior wall of EAC to be eroded leading to expansion of the EAC. The inner end of the EAC skin has turned a yellow-white color due to inflammation


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Fig. 2.35
The tympanic membrane is elevated to expose the tympanic cavity.

After the skin flap of the EAC was elevated to the tympanic annulus, a large tympanic membrane perforation could be seen with no posterior residual rim. Part of the postero-superior bony EAC wall, between the 9 o’clock and 12 o’clock positions, was eroded, exposing the chorda tympani nerve. Part of the lateral attic wall is also missing and the ossicles were surrounded by granulation tissue. The pars flaccida was carefully elevated


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Fig. 2.36
The residual epithelial and fibrous layers of the tympanic membrane were separated from the lamina propria

In this case, there was no postero-superior residual rim of the tympanic membrane. The residual posterior and inferior epithelial layer of the tympanic membrane was separated from the fibrous layer. A calcified plaque can be seen on the surface of the inferior fibrous layer of the tympanic membrane


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Fig. 2.37
The recipient bed for repairing the tympanic membrane is prepared

The residual epithelial layer of the anterior tympanic membrane is elevated. Dissection should advance evenly from the antero-superior and antero – inferior walls of the EAC and converge on the incisions. The epithelial layer of the tympanic membrane is then replaced to check its integrity. It must be separated completely from the fibrous layer in the area where the fascial graft is to be placed


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Fig. 2.38
Exposure of the ossicles

The microscope is adjusted to look superiorly. The attic was partly open due to erosion of its lateral wall. Granulation tissue surrounding the ossicular chain was cleaned up. The malleus was absent and the incus long process was mostly missing. The stapes is surrounded by swollen mucous membrane binding it to the surface of the promontory. This picture shows the incus in the process of being removed


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Fig. 2.39
Tympanic membrane is replaced

EAC tympanic membrane flap is replaced. The tympanomeatal flap is totally separated from the bony wall and the residual fibrous layer of the tympanic membrane, making the recipient bed for repairing the tympanic membrane


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Fig. 2.40
Transplanted temporalis fascia is positioned for repair of the tympanic membrane

The temporalis fascia is inserted between the epithelial and fibrous layers of the tympanic membrane. The size of fascia is important and should not be folded over, but in direct contact with the residual fibrous layer of tympanic membrane and bony wall near the tympanic sulcus. The graft should cover the perforation completely to prevent a recurrent membrane defect


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Fig. 2.41
The incus has been removed and the stapes superstructure is seen

The tympanomeatal flap with the embedded temporalis fascia is reflected forwards to expose the tympanic cavity. After the incus is taken out, the stapes superstructure is seen to be intact. The anterior and inferior tympanic cavity is filled with erythromycin soaked gelatin sponge to support the temporalis fascial graft


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Fig. 2.42
Artificial ossicle (PORP) is positioned

After cleaning the disease from around the stapes, its mobility was checked and seen to be good. The ossicular prosthesis (PORP) was positioned on the stapes head. As there was a good fit between the cup of the prosthesis and the stapes head, no additional support was necessary to hold it in correct position


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Fig. 2.43
A cartilage graft was inserted between the lateral face of the prosthesis and the temporalis fascia

In order to prevent extrusion of the prosthesis a cartilage graft is taken from the crus of helix and inserted between the lateral face of the prosthesis and the temporalis fascia. A rectangular curved cartilage graft is also used to repair the deficient postero-superior bony EAC wall in the 9–12 o’clock position to prevent retraction of the repaired tympanic membrane


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Fig. 2.44
Transplanted fascia

The fascial graft is used to cover the surface of the ossicular prosthesis and the two cartilage grafts, making sure they remain in their correct position


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Fig. 2.45
Iodoform gauze is used to pack the EAC

The tympanomeatal flap is replaced and positioned with a dissector

Care is taken to ensure the fascia covers the perforation and does not extend beyond the lateral end of the skin flap. Gelatin sponge is used to cover the lateral surface of the drum and iodoform gauze pieces are placed to pack the EAC

Surgery 2: Tympanoplasty

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Fig. 2.46
Local anesthetic is injected

10 ml of local anesthetic solution in normal saline is mixed with 10 drops of 0.1 % epinephrine and injected as local infiltration anesthesia. The injection is performed at three to four points along the junction of the cartilage and bony parts of the EAC. The needle is inserted through the lateral skin on to the EAC bone and the infiltration is performed slowly to blanch the skin and anesthetize the skin


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Fig. 2.47
The first incision

A longitudinal incision is made at the top of EAC, and extended about 1.0 cm along anterior border of the crus of helix. Any bleeding vessels are coagulated with bipolar diathermy. The inner end of the incision stops 0.8–1.0 cm lateral to the pars flaccida of the tympanic membrane. The second incision is circumferential and made 0.5 cm behind the tympanic annulus. It extends from the from the 6 o’clock position, over the posterior EAC wall to meet the medial end of the first incision


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Fig. 2.48
The second incision

The second incision is made over the posterior bony auditory canal wall from the 6 o’clock position, 0.5 cm away from the tympanic annulus, to join the inner end of the first incision. The large perforation at the center of the pars tensa and the residual tympanic membrane can be seen


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Fig. 2.49
Elevation of EAC skin flaps

The skin and periosteum of the EAC are elevated from the bony wall along incisional margin to the tympanic annulus. The anterior skin flap is elevated and the anterior superior spine is exposed with sharp and blunt dissection. Any prominent anterior superior spine is removed. This is an important part of the procedure to expose the anterior part of the tympanic membrane and of the middle ear


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Fig. 2.50
Remnant epithelial layer and fibrous layer of the tympanic membrane are separated

The skin flap of the EAC is elevated to the tympanic annulus and whole remnant epithelial layer of the tympanic membrane is separated carefully upwards, forwards and downwards. The fibrous layer of the tympanic membrane is left in situ


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Fig. 2.51
Repositioning of EAC skin flap

After replacing the tympanomeatal flap, the integrity of the epithelial layer of tympanic membrane is checked to ensure that it is completely separated from the lamina propria. Any areas of adhesion are identified and separated. The site and size of the ear drum perforation are also assessed. The epithelial layer of the tympanic membrane is preserved as far as possible


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Fig. 2.52
A segment of the lateral bony wall of postero-superior tympanic cavity is chiseled off

If exploration of the ossicular chain or attic is required, the remaining base layer of the tympanic membrane (right side from 9 to 11 o’clock) is elevated from the tympanic sulcus. Bone can be removed delicately in small pieces to extend the exposure as required, avoiding injury to the chorda tympani and the ossicular chain


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Fig. 2.53
The long process of incus and incudostapedial joint are exposed

In order to explore the integrity and mobility of the ossicular chain, bone of the postero-superior EAC wall can be removed to expand the field of vision. This picture shows the lamina propria, chorda tympani nerve, long process of incus and stapes. The ossicular chain is seen to be intact and mobile


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Fig. 2.54
Relation between chorda tympani nerve and lamina propria

Zoom in with the microscope; identify the lamina propria extending from the tympanic sulcus. The chorda tympani nerve sits under the lamina propria lateral to the long process of the incus. The handle of the malleus and remaining lamina propria surrounding it are seen in the front of the field of vision


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Fig. 2.55
Repair of tympanic membrane; replacement of tympanomeatal flap.

Harvest the temporalis fascia at the beginning of the operation and stiffen it in 75 % alcohol solution. Lay it between the epithelial layer of tympanic membrane and the lamina propria, covering the perforation completely. Replace the lateral and tympanomeatal flaps, ensuring the fascia is well seated and fully covers the perforation, and does not extend lateral to the end of the tympanomeatal flap


Reconstruction of Ossicular Chain/Ossiculoplasty



Yu-hua Zhu10 , Xue Gao10 and Pu Dai10


(10)
Department of Otolarygngology Head and Neck Surgery, PLA General Hospital, Beijing, 100853, China

 


Indications





  1. 1.


    Chronic suppurative otitis media

     

  2. 2.


    Abnormality of ossicular chain

     

  3. 3.


    Traumatic ossicular chain disruption

     

  4. 4.


    Otospongiosis (Otosclerosis)

     

  5. 5.


    Tympanosclerosis

     

  6. 6.


    Congenital cholesteatoma

    Note: Chronic suppurative otitis media is the most common indication.

     


Contraindications





  1. 1.


    Patients unfit for the operation

     

  2. 2.


    Dysfunction of Eustachian tube

     

  3. 3.


    Residual cholesteatoma in the tympanic cavity

     

  4. 4.


    Perforation of ear drum with persistent discharge

     

  5. 5.


    Acute otitis externa and otitis media

     


Operative Procedures


Different reconstructive methods and materials are used in various approaches to ossiculoplasty depending on the disease status and ossicular status (continuity and mobility). If possible, it is the best to make full use of autologous ossicles to reconstruct hearing. Maintaining the tympanic cavity and continuity and stability of the ossicular chain are two key points in ossiculoplasty.


  1. 1.


    Incision: an endaural or a postauricular incision can be used, depending on the middle ear pathology and the preference of the surgeon

     

  2. 2.


    The tympanomeatal flap, consisting of the tympanic membrane and the posterior external auditory canal skin are carefully elevated to expose the tympanic cavity adequately.

     

  3. 3.


    Expose the lateral wall of epitympanic recess and explore the malleus.

     

  4. 4.


    Open the epitympanic recess to completely remove cholesteatoma, and explore the incus and malleus.

     

  5. 5.


    The antrum and mastoid should be opened until normal air cells and mucosa are reached.

     

  6. 6.


    Evaluate the status and mobility of the residual ossicles and prepare available autologous ossicle(s) for further use.

     

  7. 7.


    Select the type of ossicle to be transplanted, measure the length required, shape the ossicle for ossicular reconstruction.

     

  8. 8.


    Reconstruction of ossicular chain: there are different types of reconstruction according to the status of the residual ossicular chain.

    A. Manubrium of malleus -Head of stapes: this is applicable for ossicular chain disruption due to a missing incus, attic fixation of the malleus head or incus body, tympanosclerosis and so on. B. Manubrium of malleus-Footplate of stapes: this is applicable for the lesions where the incus and the stapes superstructure are damaged and the malleus and footplate of stapes are intact. C. Manubrium of malleus-Oval window: it is applicable for the lesions where the incus and stapes superstructure are absent and the malleus is intact. The oval window may need to be sealed with tissue (perichondrium, fascia or vein). D. Tympanic membrane-Head of stapes: this is applicable for lesions where the incus and malleus are absent and the stapes is intact. A partial ossicular substitute (PORP) can be used to bridge the gap between the tympanic membrane and head of stapes. E. Tympanic membrane- Footplate of stapes: this is applicable for lesions including absence of the malleus, incus and superstructure of stapes, but the footplate of stapes present and mobile. A total ossicular substitute (TORP) may be used to connect the tympanic membrane and footplate of stapes.

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Jul 9, 2017 | Posted by in OTOLARYNGOLOGY | Comments Off on Mastoid and Middle Ear Surgery

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