Like anterior and posterior rhinoscopy, endoscopy of nose
and nasopharynx helps in the diagnosis of diseases of
nose, paranasal sinuses (PNS) and the nasopharynx.
Because of the brighter illumination, magnification and
angled view provided by the endoscopes, it is possible to
examine all clefts and crevices of the nose and nasopharynx.
It is an important part of examination of nose and
nasopharynx.
Indications
1. To diagnose any disease of the nose and PNS.
2. To diagnose source of bleeding in epistaxis.
3. To assess response to medical or surgical treatment
of the nose and PNS disease.
4. To take a precise biopsy from nose and nasopharynx.
Anaesthesia
Topical anaesthesia with 4% xylocaine and a vasoconstrictor
(oxymetazoline), first as a nasal spray and then
nasal packs.
Position
Sitting or supine.
Instruments
1. 4 mm 30° endoscope
2.7 mm 30° endoscope } Required when nasal
2.7 mm 70° endoscope passages are narrow
2. Freer's elevator or elevator with a suction channel
3. Suction tips
4. Biopsy forceps
5. Antifog solution or savlon to prevent fogging of the
endoscopic lens.
Technique
After nasal packs are removed, endoscopy is performed by
three passes:
First Pass (Examination of nasopharynx and
inferior meatus)
1. First obtain a general view of the nasal cavity. Look
for any septal deviation or spurs and their size,
mucous or purulent discharge in the nasal cavity and
colour of the nasal mucous membrane.
2. Pass the endoscope along the floor of nose into the
nasopharynx and examine: (i) opening of eustachian
tube, (ii) walls of nasopharynx, (iii) upper surface of
soft palate and uvula, and (iv) opening of eustachian
tube of opposite side. To see these structures endoscope
is rotated.
3. Withdraw the endoscope slightly and examine the
margins of choana and posterior ends of turbinates.
4. Withdraw endoscope slowly and at the same time
examine inferior meatus for opening of nasolacrimal
duct and Hasner's valve. Slight pressure over the
lacrimal sac may express a drop or two of lacrimal
fluid through the nasolacrimal opening.
Second Pass (Examination of the
sphenoethmoidal recess, superior meatus
and openings of sphenoid sinus and
posterior ethmoidal cells)
Endoscope is passed medial to middle turbinate to examine
posterior part of middle turbinate, sphenoethmoidal
recess, superior turbinate and meatus, opening of posterior
ethmoid cells (in the superior meatus) and opening of
sphenoid sinus in the posterior wall of sphenoethmoidal
recess between the nasal septum and superior turbinate.
Third Pass (Examination of the
middle meatus in detail)
Endoscope is passed from the front into the middle meatus.
Sometimes middle turbinate needs to be displaced medially
or 2.7 mm 30° endoscope have to be used. Examine
uncinate process, bulla ethmoidalis, hiatus semilunaris,
sinus of the turbinate (cavity on lateral side of middle
turbinate) and the frontal recess.
Sometimes middle meatus is better entered from
behind where the space is wider than from the front and
structures are seen from behind forward, e.g. basal lamina,
bulla ethmoidalis, hiatus semilunaris, sinus of the turbinate
and uncinate process and the frontal recess.
Complications
Sometimes bleeding can occur due to suction or manipulation
of instruments. It is usually mild and easily controlled
by vasoconstrictor nasal drops.
Tuesday, December 28, 2010
Submucous Resection of Nasal Septum And Septoplasty
Indications
1. Deviated nasal septum (DNS) causing symptoms of
nasal obstruction and recurrent headaches.
Z. DNS causing obstruction to ventilation of paranasal
sinuses and middle ear, resulting in recurrent sinusitis
and otitis media.
3. Recurrent epistaxis from septal spur.
4. As a part of septorhinoplasty for cosmetic correction
of external nasal deformities.
5. As a preliminary step in hypophysectomy (trans-septal
trans-sphenoidal approach) or vidian neurectomy
(trans-septal approach).
Contraindications
1. Patients below 17 years of age. In such cases, a conservative
surgery (septoplasty) should be done.
Z. Acute episode of respiratory infection.
3. Bleeding diathesis.
4. Untreated diabetes or hypertension.Anaesthesia
Local anaesthesia is preferred. General anaesthesia is
used in children and apprehensive adults.
Position
Reclining position with head-end of the table raised.
Steps of Operation
1. Infiltration of nasal septum. It is done in its subperichondrial
planes with 2% xylocaine and 1:50,000
adrenaline.
2. Incision. A curvilinear incision with forward
convexity is made at the mucocutaneous junction on the
left side of the septum. It cuts only through the mucosa
and perichondrium.
3. Elevation of mucoperichondrial and periosteal
flap. Plane of dissection is important. It should be
beneath the perichondrium and periosteum (Fig. 83.1A).
4. Incision of the cartilage. Cartilage is incised just
posterior to the first incision. Avoid cutting the opposite
mucoperichondrium, otherwise, it will result in perforation.
5. Elevation of opposite mucoperichondrium and
periosteum. With the elevator passed through the cartilage
incision, mucoperichondrial and periosteal flap is
raised from the opposite side of the septum (Fig. 83.1 B).
6. Removal of cartilage and bone. Now working
between the two flaps, cartilage and bone are removed.
Cartilage can be removed with Ballenger swivel knife
and bone with Luc's forceps. Bony spur or ridge can be
removed with gouge and hammer. Preserve a strip of cartilage
about 1 cm wide along the dorsal and caudal border
of the septum to prevent collapse of the bridge of
nose or retraction columella (Fig. 83.2).
7. Stitching. One or two catgut or silk stitches are
applied in the initial mucoperichondrial incision.
S. Packing. Ribbon gauze, smeared with an antibiotic
ointment or liquid paraffin, is packed in each nasal cavity
to prevent collection of blood between the flaps. Nasal
dressing is applied.
Post-operative Care
1. Patient is placed in semi-sitting position to prevent
oozing of blood. Outer nasal dressing is changed if
soaked in blood.
Z. A soft diet should be taken in the first two postoperative
days to minimise active mastication
which causes bleeding.
3. Pain, if any, should be controlled with analgesics.
4. Antibiotic cover is given for 5-6 days.
5. Nasal packs are gently removed after 24 hours and
thereafter, decongestant nasal drops and steam
inhalations are given daily for 5-6 days.
6. Silk stitch, if any, is removed on 5th or 6th day.
7. Patient should avoid trauma to the nose for
several days.
Compl ications
1. Bleeding. It may require repacking, if severe.
2. Septal haemawma. Evacuate the haematoma and
given intranasal packing on both sides of septum for
equal pressure.
3. Septal abscess. This can follow infection of septal
haematoma.
4. Perforation. When tears occur on opposing side of
mucous membrane.
5. Depression of bridge. Usually occurs in supratip area
due to too much removal of cartilage along the dorsal
border.
6. Retraction of columella. Often seen when caudal strip
of cartilage is not preserved.
7. Persistence of deviation. It usually occurs due to inadequate
surgery and may require revision operation.
8. Flapping of nasal septum. Rarely seen, when too much
of septal framework has been removed. Septum,
which now consists of two mucoperichondrial flaps,
moves to the right or left with respiration.
9. Toxic shock syndrome. It is rare after septal surgery. It
can follow staphylococcal (sometimes streptococcal)
infection and is characterised by nausea, vomiting,
purulent secretions, hypotension and rash. It should
be diagnosed early. It is treated by removal of packing,
hydrating the patient, maintaining blood pressure and
administering proper antibiotics.
SEPTOPLASTY:
Septoplasty is a conservative approach to septal surgery; as
much of the septal framework as possible is retained.
Mucoperichondrial/periosteal flap is generally ra ised
only on one side. This operation has almost replaced the
SMR operation.
Indications
1. Symptomatic deviated septum.
2. As a part of septorhinoplasty for cosmetic reasons.
3. As an approach to hypophysectomy.
4. Recurrent epistaxis due to septal spur.
Contraindications
1. Acute nasal or sinus infection.
2. Untreated diabetes.
3 . Hypertension.
4. Bleeding diathesis.
Anaesthesia
Local or general.
Position
Same as for SMR operation.Technique
1. Infiltrate the septum with 1 % lignocaine with ad renaline,
1:100,000.
2. In cases of deviated septum, make a slightly curvilinear
incision, 2-3 mm above the caudal end of septal
cartilage on the concave side (Killian's incision).
In case of caudal dislocation, a transfix ion or hemitransfixion
(Freer's) incision is made.
3. Raise mucoperichondrial/mucoperiosteal flap on
one side only.
4. Separate septal cartilage from the vomer and ethmoid
plate and raise mucoperiosteal flap on the opposite
side of septum.
5. Remove maxillary crest to realign the septal cartilage.
6. Correct the bony septum by removing the deformed
parts. Deformed septal cartilage is corrected by various
methods, such as:
(i) Scoring on the concave side (Fig. 84.1).
(ii) Cross-hatching or morcelizing.
(iii) Shaving.
(iv) Wedge excision.
Further manipulations like realignment of nasal spine,
separation of septal cartilage from upper lateral cartilages,
implantation of cartilage strip in the columella
or the dorsum of nose may be required.
7. Trans-septal sutures are put to coapt mucoperichondrial
flaps.
8. Nasal pack.
Post-operative Complications
Same as for SMR operation.
1. Bleeding.
2. Septal haernatorna and abscess.
3. Septal perforation.
4. Persistence of septal deviation, or external nasal
deformity.
1. Deviated nasal septum (DNS) causing symptoms of
nasal obstruction and recurrent headaches.
Z. DNS causing obstruction to ventilation of paranasal
sinuses and middle ear, resulting in recurrent sinusitis
and otitis media.
3. Recurrent epistaxis from septal spur.
4. As a part of septorhinoplasty for cosmetic correction
of external nasal deformities.
5. As a preliminary step in hypophysectomy (trans-septal
trans-sphenoidal approach) or vidian neurectomy
(trans-septal approach).
Contraindications
1. Patients below 17 years of age. In such cases, a conservative
surgery (septoplasty) should be done.
Z. Acute episode of respiratory infection.
3. Bleeding diathesis.
4. Untreated diabetes or hypertension.Anaesthesia
Local anaesthesia is preferred. General anaesthesia is
used in children and apprehensive adults.
Position
Reclining position with head-end of the table raised.
Steps of Operation
1. Infiltration of nasal septum. It is done in its subperichondrial
planes with 2% xylocaine and 1:50,000
adrenaline.
2. Incision. A curvilinear incision with forward
convexity is made at the mucocutaneous junction on the
left side of the septum. It cuts only through the mucosa
and perichondrium.
3. Elevation of mucoperichondrial and periosteal
flap. Plane of dissection is important. It should be
beneath the perichondrium and periosteum (Fig. 83.1A).
4. Incision of the cartilage. Cartilage is incised just
posterior to the first incision. Avoid cutting the opposite
mucoperichondrium, otherwise, it will result in perforation.
5. Elevation of opposite mucoperichondrium and
periosteum. With the elevator passed through the cartilage
incision, mucoperichondrial and periosteal flap is
raised from the opposite side of the septum (Fig. 83.1 B).
6. Removal of cartilage and bone. Now working
between the two flaps, cartilage and bone are removed.
Cartilage can be removed with Ballenger swivel knife
and bone with Luc's forceps. Bony spur or ridge can be
removed with gouge and hammer. Preserve a strip of cartilage
about 1 cm wide along the dorsal and caudal border
of the septum to prevent collapse of the bridge of
nose or retraction columella (Fig. 83.2).
7. Stitching. One or two catgut or silk stitches are
applied in the initial mucoperichondrial incision.
S. Packing. Ribbon gauze, smeared with an antibiotic
ointment or liquid paraffin, is packed in each nasal cavity
to prevent collection of blood between the flaps. Nasal
dressing is applied.
Post-operative Care
1. Patient is placed in semi-sitting position to prevent
oozing of blood. Outer nasal dressing is changed if
soaked in blood.
Z. A soft diet should be taken in the first two postoperative
days to minimise active mastication
which causes bleeding.
3. Pain, if any, should be controlled with analgesics.
4. Antibiotic cover is given for 5-6 days.
5. Nasal packs are gently removed after 24 hours and
thereafter, decongestant nasal drops and steam
inhalations are given daily for 5-6 days.
6. Silk stitch, if any, is removed on 5th or 6th day.
7. Patient should avoid trauma to the nose for
several days.
Compl ications
1. Bleeding. It may require repacking, if severe.
2. Septal haemawma. Evacuate the haematoma and
given intranasal packing on both sides of septum for
equal pressure.
3. Septal abscess. This can follow infection of septal
haematoma.
4. Perforation. When tears occur on opposing side of
mucous membrane.
5. Depression of bridge. Usually occurs in supratip area
due to too much removal of cartilage along the dorsal
border.
6. Retraction of columella. Often seen when caudal strip
of cartilage is not preserved.
7. Persistence of deviation. It usually occurs due to inadequate
surgery and may require revision operation.
8. Flapping of nasal septum. Rarely seen, when too much
of septal framework has been removed. Septum,
which now consists of two mucoperichondrial flaps,
moves to the right or left with respiration.
9. Toxic shock syndrome. It is rare after septal surgery. It
can follow staphylococcal (sometimes streptococcal)
infection and is characterised by nausea, vomiting,
purulent secretions, hypotension and rash. It should
be diagnosed early. It is treated by removal of packing,
hydrating the patient, maintaining blood pressure and
administering proper antibiotics.
SEPTOPLASTY:
Septoplasty is a conservative approach to septal surgery; as
much of the septal framework as possible is retained.
Mucoperichondrial/periosteal flap is generally ra ised
only on one side. This operation has almost replaced the
SMR operation.
Indications
1. Symptomatic deviated septum.
2. As a part of septorhinoplasty for cosmetic reasons.
3. As an approach to hypophysectomy.
4. Recurrent epistaxis due to septal spur.
Contraindications
1. Acute nasal or sinus infection.
2. Untreated diabetes.
3 . Hypertension.
4. Bleeding diathesis.
Anaesthesia
Local or general.
Position
Same as for SMR operation.Technique
1. Infiltrate the septum with 1 % lignocaine with ad renaline,
1:100,000.
2. In cases of deviated septum, make a slightly curvilinear
incision, 2-3 mm above the caudal end of septal
cartilage on the concave side (Killian's incision).
In case of caudal dislocation, a transfix ion or hemitransfixion
(Freer's) incision is made.
3. Raise mucoperichondrial/mucoperiosteal flap on
one side only.
4. Separate septal cartilage from the vomer and ethmoid
plate and raise mucoperiosteal flap on the opposite
side of septum.
5. Remove maxillary crest to realign the septal cartilage.
6. Correct the bony septum by removing the deformed
parts. Deformed septal cartilage is corrected by various
methods, such as:
(i) Scoring on the concave side (Fig. 84.1).
(ii) Cross-hatching or morcelizing.
(iii) Shaving.
(iv) Wedge excision.
Further manipulations like realignment of nasal spine,
separation of septal cartilage from upper lateral cartilages,
implantation of cartilage strip in the columella
or the dorsum of nose may be required.
7. Trans-septal sutures are put to coapt mucoperichondrial
flaps.
8. Nasal pack.
Post-operative Complications
Same as for SMR operation.
1. Bleeding.
2. Septal haernatorna and abscess.
3. Septal perforation.
4. Persistence of septal deviation, or external nasal
deformity.
Caldwell-Luc Operation
Caldwell-Luc operation is a process of opening the maxillary
antrum through canine fossa by sublabial approach
and dealing with the pathology inside the antrum.
Indications
1. Chronic maxillary sinusitis with irreversible changes
in the sinus mucosa.
2. Removal of foreign bodies or root of tooth.
3. Dental cyst.
4. Oroantral fistula.
5. Suspected neoplasm in the antrum and its biopsy.
6. Recurrent antrochoanal polyp.
7. Fracture of maxilla or blow-out fractures of the orbit.
8. As an approach to ethmoids (Horgan's transantral
ethmoidectomy) .
9. Approach to pterygopalatine fossa for ligation of
maxillary artery.
10. Vidian neurectomy.
Contra indications
Patient below 17 years of age.
Anaesthesia
General anaesthesia with cuffed endotracheal tube and a
pharyngeal pack. Can be done under local anaesthesia.
Position
Reclining with head-end of the table raised. Patient lies
supine with face turned slightly to the opposite side.
Technique
1. Incision. A horizontal incision with its ends upward
is made below the gingivolabial sulcus, from lateral incisor
A
to the 2nd molar (Fig. 82.1). It cuts through mucous
membrane and periosteum.
2. Elevation of flap. The mucoperiosteal flap is raised
from the canine fossa to the infraorbital nerve avoiding
injury to the nerve .
3. Opening the antrum. Using cutting burr or gouge
and hammer, a hole is made in the antrum. Opening is
enlarged using Kerrison's punch.
4. Dealing with pathology. Once maxillary antrum
has been opened, pathology is removed. Diseased antral
mucosa can be removed with elevators, curettes and
forceps. Cyst, benign tumour, foreign body or a polyp is
removed .
5. Making nasoantral window. A curved haemostat
is pushed into the antrum from the inferior meatus and
then this opening is enlarged with Kerrison's and sidebiting
forceps to make a window, 1.5 cm in diameter.
6. Packing the antrum. Rihhon gauze. impregnated
with liquid paraffin or Furacin ™ (Furacin ™ is 0.2% w/w
nitrofurazone) ointment can be packed in the antrum
and its end brought out from the nasoantral window into
the nose. Intrasinus packing is done if there is severe
bleeding. Pack is also kept in the nose.
7. Closure of wound. Sublabial incision is closed
with one or two catgut sutures.
Post-operative Care
1. Ice packs over the cheek in the fi rst 24 hours prevent
oedema. haematoma and discomfort to the patient.
2. Packing in the sinus and nose can be removed in
24-48 hours.3. Antibiotics are given for 5-7 days.
4. Patient should avoid blowing his nose for 2 weeks to
avoid surgical emphysema.
Complications
1. Post-operative bleeding. This can be controlled by
nasal pack.
2. Anaesthesia of the cheek due to stretching of
infraorbital nerve. It may last for a few weeks or
months.
3. Anaesthesia of teeth.
4. Injury to nasolacrimal duct.
5. Sublabial fistula .
6. Osteomyelitis of maxilla (rare).
antrum through canine fossa by sublabial approach
and dealing with the pathology inside the antrum.
Indications
1. Chronic maxillary sinusitis with irreversible changes
in the sinus mucosa.
2. Removal of foreign bodies or root of tooth.
3. Dental cyst.
4. Oroantral fistula.
5. Suspected neoplasm in the antrum and its biopsy.
6. Recurrent antrochoanal polyp.
7. Fracture of maxilla or blow-out fractures of the orbit.
8. As an approach to ethmoids (Horgan's transantral
ethmoidectomy) .
9. Approach to pterygopalatine fossa for ligation of
maxillary artery.
10. Vidian neurectomy.
Contra indications
Patient below 17 years of age.
Anaesthesia
General anaesthesia with cuffed endotracheal tube and a
pharyngeal pack. Can be done under local anaesthesia.
Position
Reclining with head-end of the table raised. Patient lies
supine with face turned slightly to the opposite side.
Technique
1. Incision. A horizontal incision with its ends upward
is made below the gingivolabial sulcus, from lateral incisor
A
to the 2nd molar (Fig. 82.1). It cuts through mucous
membrane and periosteum.
2. Elevation of flap. The mucoperiosteal flap is raised
from the canine fossa to the infraorbital nerve avoiding
injury to the nerve .
3. Opening the antrum. Using cutting burr or gouge
and hammer, a hole is made in the antrum. Opening is
enlarged using Kerrison's punch.
4. Dealing with pathology. Once maxillary antrum
has been opened, pathology is removed. Diseased antral
mucosa can be removed with elevators, curettes and
forceps. Cyst, benign tumour, foreign body or a polyp is
removed .
5. Making nasoantral window. A curved haemostat
is pushed into the antrum from the inferior meatus and
then this opening is enlarged with Kerrison's and sidebiting
forceps to make a window, 1.5 cm in diameter.
6. Packing the antrum. Rihhon gauze. impregnated
with liquid paraffin or Furacin ™ (Furacin ™ is 0.2% w/w
nitrofurazone) ointment can be packed in the antrum
and its end brought out from the nasoantral window into
the nose. Intrasinus packing is done if there is severe
bleeding. Pack is also kept in the nose.
7. Closure of wound. Sublabial incision is closed
with one or two catgut sutures.
Post-operative Care
1. Ice packs over the cheek in the fi rst 24 hours prevent
oedema. haematoma and discomfort to the patient.
2. Packing in the sinus and nose can be removed in
24-48 hours.3. Antibiotics are given for 5-7 days.
4. Patient should avoid blowing his nose for 2 weeks to
avoid surgical emphysema.
Complications
1. Post-operative bleeding. This can be controlled by
nasal pack.
2. Anaesthesia of the cheek due to stretching of
infraorbital nerve. It may last for a few weeks or
months.
3. Anaesthesia of teeth.
4. Injury to nasolacrimal duct.
5. Sublabial fistula .
6. Osteomyelitis of maxilla (rare).
Myringoplasty
Closure of perforation of pars tensa of the tympanic membrane
is called myringoplasty. It has the advantage of:
(i) restoring the hearing loss and in some cases the
tinnitus.
(ii) checking re-infection from external auditory canal
and eustachian tube (nasopharyngeal infection
ascends easily via eustachian tube in the presence
of perforation than otherwise).
(iii) checking aeroallergens reaching the exposed middle
ear mucosa, leading to persistent ear discharge.
Myringoplasty can be combined with ossicular reconstruction
when it is called tympanoplasty.
Physiologic principles for middle ear reconstruction
are discussed on page 32.
Contra indications
(i) Active discharge from the middle ear.
(ii) Nasal allergy. It should be brought under control
before surgery.
(iii) Otitis extema.
(iv) Ingrowth of squamous epithelium into the middle
ear. In such cases, excision of squamous epithelium
from the middle ear or a tympanomastoidectomy
may be required.
(v) When the other ear is dead or not suitable for
hearing aid rehabilitation.
(vi) Children below 3 years.
Anaesthesia
Local or general, the former is preferred.
Position
Supine with face turned to one side; the ear to be operated
is up.
Graft materials used are:
(i) Temporalis fascia (most common),
(ii) Perichondrium from the tragus,
(iii) Tragal cartilage,
(iv) Vein.
Incision for exposure of tympanic membrane depends
on the size of the ear canal; it may be endomeatal, endaural
or posta ural.
Technique
Underlay Technique
1. Harvesting the graft of temporal is fascia or perichondrium
from the tragus.
2. Preparing the T.M. for grafting. An incision is
made along the edge of perforation and the ring of
epithelium removed. Remove also a strip of mucosal
layer from the inner side of perforation.
3. Inspecting the middle ear. A stapes-type incision
is made and the tympanomeatal flap raised to see the
integrity and mobility of the ossicular chain and to
ensure that no squamous epithelium has grown into the
middle ear.
4. Placing the graft. Middle ear is packed with
gelfoam soaked with an antibiotic. A proper sized graft is
placed so that its edges extend under the margins of perforation
all round and a small part also extends over the
posterior canal wall. Tympanomeatal flap is replaced. An
underlay technique has the advantage that the squamous
epithelium is not buried in the middle ear.
Overlay Technique
1. Temporal fascia or perichondrial graft is harvested as
above.
2. Incision is made in the meatus as shown (Fig. 79.1)
and meatal skin raised along with all epithelium from the
outer surface of tympanic membrane remnant.
3. Graft placed on the outer surface of TM. A slit is
made in the graft to tuck it under the handle of malleus.
4. Meatal skin removed earlier is now replaced, covering
the periphery of the graft. Ear canal packed with gelfoam
and then with a small antibiotic pack.
A modification of the overlay technique is to place
the anterior edge of fascia graft under the annulus after
removing the epithelium. This prevents blunting of anterior
canal which is seen as a complication of overlay
technique .
5. Closure of endaural or postaural incision.
6. Mastoid dressing.
Post-operative Care
l. Stitches are removed after 5-6 days.
2. Ear pack is removed after 5-6 days without disturbing
the gelfoam.
3. Patient is seen at 3 and 6 weeks after operation.
4. Complete epithelialisation of graft takes 6-8 weeks.
Complications
Underlay Technique
l. Middle ear becomes narrow.
2. Graft may get adherent to the promontory.
3. Anteriorly, graft may lose contact from the remnant of
tympanic membrane leading to anterior perforation.
Overlay Technique
l. Blunting of the anterior sulcus.
2.Epithelial pearls. They are epidermal cysts, when
squamous epithelium is buried under the graft.
3.Lateralisation of graft. Graft loses contact from the
malleus handle resulting in conductive loss. It is prevented
by tucking the graft under the handle.
Other Procedures for Closure of Tympanic
Membrane Perforation
1. Splintage. It is used in fresh traumatic perforations.
The torn edges of the petforation are carefully everted
lmder the microscope and splinted with absorbable gelfoam
placed in the middle ear through the tear. Smaller tears can
be splinted on the outer surface of the tympanic membrane
with a piece of cigarette paper, gelfilm or silicon sheet.
2. Cautery-patching. This is useful in small, longstanding
central perforations where the margins, have
become epithelialised and chronic. In this procedure,
margins, of the perforation are cauterised with 50%
trichloracetic acid to remove the epithelialised edge (or
freshened with a fine pick used for myringoplasty) and
then supported with a cigarette paper moistened with
1 % phenol in glycerine. This procedure can be repeated
at two weeks interval. Instead of cigarette paper, other
material such as steristrip, gelfilm or silicone sheets have
also been used .
3. Fat-graft myringoplasty. It is also used to close
small perforations. After local anaesthesia, edges of perforation
are freshened with 1 mm stapes hook. The inside
of perforation is also scrapped. A small piece of fat harvested
from the ear lobule is plugged into the perforation
like an hour-glass. Over a time, the fat graft adheres and
closes the perforation.
is called myringoplasty. It has the advantage of:
(i) restoring the hearing loss and in some cases the
tinnitus.
(ii) checking re-infection from external auditory canal
and eustachian tube (nasopharyngeal infection
ascends easily via eustachian tube in the presence
of perforation than otherwise).
(iii) checking aeroallergens reaching the exposed middle
ear mucosa, leading to persistent ear discharge.
Myringoplasty can be combined with ossicular reconstruction
when it is called tympanoplasty.
Physiologic principles for middle ear reconstruction
are discussed on page 32.
Contra indications
(i) Active discharge from the middle ear.
(ii) Nasal allergy. It should be brought under control
before surgery.
(iii) Otitis extema.
(iv) Ingrowth of squamous epithelium into the middle
ear. In such cases, excision of squamous epithelium
from the middle ear or a tympanomastoidectomy
may be required.
(v) When the other ear is dead or not suitable for
hearing aid rehabilitation.
(vi) Children below 3 years.
Anaesthesia
Local or general, the former is preferred.
Position
Supine with face turned to one side; the ear to be operated
is up.
Graft materials used are:
(i) Temporalis fascia (most common),
(ii) Perichondrium from the tragus,
(iii) Tragal cartilage,
(iv) Vein.
Incision for exposure of tympanic membrane depends
on the size of the ear canal; it may be endomeatal, endaural
or posta ural.
Technique
Underlay Technique
1. Harvesting the graft of temporal is fascia or perichondrium
from the tragus.
2. Preparing the T.M. for grafting. An incision is
made along the edge of perforation and the ring of
epithelium removed. Remove also a strip of mucosal
layer from the inner side of perforation.
3. Inspecting the middle ear. A stapes-type incision
is made and the tympanomeatal flap raised to see the
integrity and mobility of the ossicular chain and to
ensure that no squamous epithelium has grown into the
middle ear.
4. Placing the graft. Middle ear is packed with
gelfoam soaked with an antibiotic. A proper sized graft is
placed so that its edges extend under the margins of perforation
all round and a small part also extends over the
posterior canal wall. Tympanomeatal flap is replaced. An
underlay technique has the advantage that the squamous
epithelium is not buried in the middle ear.
Overlay Technique
1. Temporal fascia or perichondrial graft is harvested as
above.
2. Incision is made in the meatus as shown (Fig. 79.1)
and meatal skin raised along with all epithelium from the
outer surface of tympanic membrane remnant.
3. Graft placed on the outer surface of TM. A slit is
made in the graft to tuck it under the handle of malleus.
4. Meatal skin removed earlier is now replaced, covering
the periphery of the graft. Ear canal packed with gelfoam
and then with a small antibiotic pack.
A modification of the overlay technique is to place
the anterior edge of fascia graft under the annulus after
removing the epithelium. This prevents blunting of anterior
canal which is seen as a complication of overlay
technique .
5. Closure of endaural or postaural incision.
6. Mastoid dressing.
Post-operative Care
l. Stitches are removed after 5-6 days.
2. Ear pack is removed after 5-6 days without disturbing
the gelfoam.
3. Patient is seen at 3 and 6 weeks after operation.
4. Complete epithelialisation of graft takes 6-8 weeks.
Complications
Underlay Technique
l. Middle ear becomes narrow.
2. Graft may get adherent to the promontory.
3. Anteriorly, graft may lose contact from the remnant of
tympanic membrane leading to anterior perforation.
Overlay Technique
l. Blunting of the anterior sulcus.
2.Epithelial pearls. They are epidermal cysts, when
squamous epithelium is buried under the graft.
3.Lateralisation of graft. Graft loses contact from the
malleus handle resulting in conductive loss. It is prevented
by tucking the graft under the handle.
Other Procedures for Closure of Tympanic
Membrane Perforation
1. Splintage. It is used in fresh traumatic perforations.
The torn edges of the petforation are carefully everted
lmder the microscope and splinted with absorbable gelfoam
placed in the middle ear through the tear. Smaller tears can
be splinted on the outer surface of the tympanic membrane
with a piece of cigarette paper, gelfilm or silicon sheet.
2. Cautery-patching. This is useful in small, longstanding
central perforations where the margins, have
become epithelialised and chronic. In this procedure,
margins, of the perforation are cauterised with 50%
trichloracetic acid to remove the epithelialised edge (or
freshened with a fine pick used for myringoplasty) and
then supported with a cigarette paper moistened with
1 % phenol in glycerine. This procedure can be repeated
at two weeks interval. Instead of cigarette paper, other
material such as steristrip, gelfilm or silicone sheets have
also been used .
3. Fat-graft myringoplasty. It is also used to close
small perforations. After local anaesthesia, edges of perforation
are freshened with 1 mm stapes hook. The inside
of perforation is also scrapped. A small piece of fat harvested
from the ear lobule is plugged into the perforation
like an hour-glass. Over a time, the fat graft adheres and
closes the perforation.
Radical Mastoidectomy
Radical Mastoidectomy is a procedure to eradicate disease
from the middle ear and mastoid without any attempt to
reconstruct hearing. Posterior meatal wall is removed and
the entire area of middle ear, attic, antrum and mastoid is
converted into a single cavity. All remnants of tympanic
membrane, ossicles (except stapes footplate) and mucoperiosteallining
are removed (Fig. 77.1). Eustachian tube is
obliterated by a piece of muscle or cartilage. Aim of the
operation is to permanently exteriorise the diseased area
for inspection and cleaning. The radical mastoidectomy is
infrequently required these days.
Indications
1. When all cholesteatoma cannot be safely removed,
e.g. that invading eustachian tube, round window
niche, perilabyrinthine or hypotympanic cells.
2. If previous attempts to eradicate chronic inflammatory
disease or cholesteatoma have failed.
3. As an approach to petrous apex.
4. Removal of glomus tumour.
5. Carcinoma middle ear. Radical mastoidectomy followed
by radiotherapy is an alternative to en bloc
removal of temporal bone in carcinoma middle ear.
Anaesthesia
Mos tly, general anaesthesia is given. Local anaesthesia
can be used in selected cases.
Position
Patient lies supine with face turned to one side and the
ear to be operated upper-most.
Steps of Operation
1. Incision. Postaural (Fig. 77.2) or endaural
(Fig. 77.3).
Horizontol
Eust. tube
opening closed
with muscle
ROIJr:vl w.i.r.I.rlnw
Fig. 77.1 Radical mastoidectomy. The entire area of
mastoid, middle ear, attic and antrum is exteriorised.
Eustachian tube is obliterated and no attempt is made to
reconstruct the hearing mechanism .
2. Retraction of soft tissues and exposure of mastoid
area. Mastoid area from posterior root of zygoma to
behind the suprameatal triangle and from temporal line
above to the lower part of mastoid tip below is exposed
by elevating the periosteum and the wound retracted.
3. Removal of bone and exposure of attic and
antrum. With the help of burr, bone is removed from
the area of suprameatal triangle, spine of Henle, root of
zygoma to just above the anterior meatal wall, upper part
of superior meatal wall is also removed. This will expose
attic and antrum. Identify the tegmen antri and lateral
semicircular canal.4. Removal of the "bridge" and the buttresses.
Deeper part of superior osseous meatal wall that bridges
over the notch of Rivinus is removed.
Anterior spine of the notch (anterior buttress) and
posterIor spIne of th.e notc.h. (posterior buttre",,) are abo
removeJ. This removes the late ral attic wall. The incus
and the malleus are also removed.
5. Lowering the facial ridge. The deeper part of posterior
meatal wall that overlies the vertical part of facial
nerve is called facial ridge. It is removed as much as possible
within the safety of VIIth nerve so that the mastoid
cavity is freely accessible from the meatus.
6. Toilet of middle ear. Remnants of tympanic
membrane with its annulus and sulcus tympanicus are
removed. Middle ear mucoperiosteum along with any
polyp or granulation tissue is removed. Malleus and incus
are removed if not already done. Stapes is left intact.
Eustachian tube opening is closed by curetting its mucosa
and plugging the opening with tensor tympani muscle or
piece of cartilage.
7. Inspection of the cavity and irrigation. It is necessary
to ensure complete exteriorisation of the attic,
antrum and middle ear and mastoid cavity into external
aud itory meatus . Any bony overhangs are removed and
cavity smoothened with polishing burr. Finally, it is irri gated
with saline to remove any blood or bone particles.
8. MeatopIasty. A flap, based laterally at the concha
is raised from posterior and superior meatal wall and
turned into the mastoid cavity to cover the area of the
facial ridge. This helps in the epithelialisation of the
mastoid cavity. A piece of conchal cartilage can be
removed to enlarge the meatus and to facilitate inspection
and access to cavity.
9. Obliteration of the cavity. If mastoid cavity is
very large, it may be obliterated with temporalis muscle
or other soft tissues, taking care that no vestige of disease
(cholesteatoma) is buried underneath .
10. Closure of wound. The cavity is packed with
ribbon gauze, impregnated with an antibiotic/antiseptic
and the wound is dosed withmterrupted suture:.
Masto id dressing is applied.
Post-operative Care
1. Dressing. First dressing is done on 3rd or 4th day
Replace the outer gauze and cotton and look for any
signs of perichondritis or infection of meatal pack.
Second dressing is done on 6th or 7th day when stittches
are removed and meatal pack is changed. Thereafter
change the pack at weekly intervals or leave the cavity
unpacked with regul ar suction and cleaning till
epithelialisation is complete.
2. Antibiotic. A suitable antibiotic is given for about
week.
3. Cavity care. Usually, cavity is fully epithelialised in
2-3 months. It shou ld be period ically checked (every
4-6 months) in the first year and then annually .
removal of any debris or infection. Any granulation tissue
which delays epithelialisation is removed or cauterized.
Complications
1. Fac ial paralysis.
2. Perichondritis of pinna.
3. Injury to dura or sigmoid sinus.
4. Labyrinthitis, if stapes gets dislocated.
5. Severe conductive deafness of 50 dB or more. This
due to removal of all ossicles and tympanic membrane.
6. Cavity problems. Twenty five percent of the cavities
do not heal and continue to discharge, require
regular after-care.
Modified Radical Mastoidectomy: It is a modification of radical mastoidectomy where as
much of the hearing mechanism as possible is preserved.
The disease process which is often localised to the attic
and antrum is removed and the whole area fully exteriorised
into the meatus by removal of the posterior meatal
and lateral attic wall (Fig. 78.1).
Indications
1. Cholesteatoma confined to the attic and antrum.
2. Localised chronic otitis media.
Irreversibly damaged tissues are removed, preserving
the rest to conserve or reconstruct hearing mechanism.
Anaesthesia
Mostly general, local anaesthesia can be used in selected
cases.
Position
Same as for cortical mastoidectomy.
Steps of Operation
1. Incision, postaural or endaural.
2. Retraction of soft tissues and exposure of mastoid
area.
3. Removal of cortical bone and exposure of antrum
and attic.
Steps 2 and 3 are the same as in radical mastoidectomy.
4. Removal of diseased tissue. Cholesteatoma, granulations
or unhealthy mucosa is removed. Incus and head
of malleus often require removal, if cholesteatoma
engulfs them or extends medial to them. They are
preserved if possible. Lateral attic wall is removed
to fully exteriorise the attic.
5. Facial ridge is lowered.
6. Mastoid cavity is smoothened with polishing burr,
removing any overhangs and then irrigated with
normal saline.
7. Reconstruction of hearing mechanism. Pars tensa of
tympanic membrane and middle ear, if healthy, are left
undisturbed. If disease extends into middle ear, only
the irreversible tissues are removed. Reconstruction
of tympanic membrane or ossicular chain, if damaged,
can also be done (mastoidectomy with tympanoplasty
operation) .
8. Meatoplasty and closure of wound is same as in
radica l mastoidectomy.
Post-operative Care and Complications
Same as in radical mastoidectomy.
from the middle ear and mastoid without any attempt to
reconstruct hearing. Posterior meatal wall is removed and
the entire area of middle ear, attic, antrum and mastoid is
converted into a single cavity. All remnants of tympanic
membrane, ossicles (except stapes footplate) and mucoperiosteallining
are removed (Fig. 77.1). Eustachian tube is
obliterated by a piece of muscle or cartilage. Aim of the
operation is to permanently exteriorise the diseased area
for inspection and cleaning. The radical mastoidectomy is
infrequently required these days.
Indications
1. When all cholesteatoma cannot be safely removed,
e.g. that invading eustachian tube, round window
niche, perilabyrinthine or hypotympanic cells.
2. If previous attempts to eradicate chronic inflammatory
disease or cholesteatoma have failed.
3. As an approach to petrous apex.
4. Removal of glomus tumour.
5. Carcinoma middle ear. Radical mastoidectomy followed
by radiotherapy is an alternative to en bloc
removal of temporal bone in carcinoma middle ear.
Anaesthesia
Mos tly, general anaesthesia is given. Local anaesthesia
can be used in selected cases.
Position
Patient lies supine with face turned to one side and the
ear to be operated upper-most.
Steps of Operation
1. Incision. Postaural (Fig. 77.2) or endaural
(Fig. 77.3).
Horizontol
Eust. tube
opening closed
with muscle
ROIJr:vl w.i.r.I.rlnw
Fig. 77.1 Radical mastoidectomy. The entire area of
mastoid, middle ear, attic and antrum is exteriorised.
Eustachian tube is obliterated and no attempt is made to
reconstruct the hearing mechanism .
2. Retraction of soft tissues and exposure of mastoid
area. Mastoid area from posterior root of zygoma to
behind the suprameatal triangle and from temporal line
above to the lower part of mastoid tip below is exposed
by elevating the periosteum and the wound retracted.
3. Removal of bone and exposure of attic and
antrum. With the help of burr, bone is removed from
the area of suprameatal triangle, spine of Henle, root of
zygoma to just above the anterior meatal wall, upper part
of superior meatal wall is also removed. This will expose
attic and antrum. Identify the tegmen antri and lateral
semicircular canal.4. Removal of the "bridge" and the buttresses.
Deeper part of superior osseous meatal wall that bridges
over the notch of Rivinus is removed.
Anterior spine of the notch (anterior buttress) and
posterIor spIne of th.e notc.h. (posterior buttre",,) are abo
removeJ. This removes the late ral attic wall. The incus
and the malleus are also removed.
5. Lowering the facial ridge. The deeper part of posterior
meatal wall that overlies the vertical part of facial
nerve is called facial ridge. It is removed as much as possible
within the safety of VIIth nerve so that the mastoid
cavity is freely accessible from the meatus.
6. Toilet of middle ear. Remnants of tympanic
membrane with its annulus and sulcus tympanicus are
removed. Middle ear mucoperiosteum along with any
polyp or granulation tissue is removed. Malleus and incus
are removed if not already done. Stapes is left intact.
Eustachian tube opening is closed by curetting its mucosa
and plugging the opening with tensor tympani muscle or
piece of cartilage.
7. Inspection of the cavity and irrigation. It is necessary
to ensure complete exteriorisation of the attic,
antrum and middle ear and mastoid cavity into external
aud itory meatus . Any bony overhangs are removed and
cavity smoothened with polishing burr. Finally, it is irri gated
with saline to remove any blood or bone particles.
8. MeatopIasty. A flap, based laterally at the concha
is raised from posterior and superior meatal wall and
turned into the mastoid cavity to cover the area of the
facial ridge. This helps in the epithelialisation of the
mastoid cavity. A piece of conchal cartilage can be
removed to enlarge the meatus and to facilitate inspection
and access to cavity.
9. Obliteration of the cavity. If mastoid cavity is
very large, it may be obliterated with temporalis muscle
or other soft tissues, taking care that no vestige of disease
(cholesteatoma) is buried underneath .
10. Closure of wound. The cavity is packed with
ribbon gauze, impregnated with an antibiotic/antiseptic
and the wound is dosed withmterrupted suture:.
Masto id dressing is applied.
Post-operative Care
1. Dressing. First dressing is done on 3rd or 4th day
Replace the outer gauze and cotton and look for any
signs of perichondritis or infection of meatal pack.
Second dressing is done on 6th or 7th day when stittches
are removed and meatal pack is changed. Thereafter
change the pack at weekly intervals or leave the cavity
unpacked with regul ar suction and cleaning till
epithelialisation is complete.
2. Antibiotic. A suitable antibiotic is given for about
week.
3. Cavity care. Usually, cavity is fully epithelialised in
2-3 months. It shou ld be period ically checked (every
4-6 months) in the first year and then annually .
removal of any debris or infection. Any granulation tissue
which delays epithelialisation is removed or cauterized.
Complications
1. Fac ial paralysis.
2. Perichondritis of pinna.
3. Injury to dura or sigmoid sinus.
4. Labyrinthitis, if stapes gets dislocated.
5. Severe conductive deafness of 50 dB or more. This
due to removal of all ossicles and tympanic membrane.
6. Cavity problems. Twenty five percent of the cavities
do not heal and continue to discharge, require
regular after-care.
Modified Radical Mastoidectomy: It is a modification of radical mastoidectomy where as
much of the hearing mechanism as possible is preserved.
The disease process which is often localised to the attic
and antrum is removed and the whole area fully exteriorised
into the meatus by removal of the posterior meatal
and lateral attic wall (Fig. 78.1).
Indications
1. Cholesteatoma confined to the attic and antrum.
2. Localised chronic otitis media.
Irreversibly damaged tissues are removed, preserving
the rest to conserve or reconstruct hearing mechanism.
Anaesthesia
Mostly general, local anaesthesia can be used in selected
cases.
Position
Same as for cortical mastoidectomy.
Steps of Operation
1. Incision, postaural or endaural.
2. Retraction of soft tissues and exposure of mastoid
area.
3. Removal of cortical bone and exposure of antrum
and attic.
Steps 2 and 3 are the same as in radical mastoidectomy.
4. Removal of diseased tissue. Cholesteatoma, granulations
or unhealthy mucosa is removed. Incus and head
of malleus often require removal, if cholesteatoma
engulfs them or extends medial to them. They are
preserved if possible. Lateral attic wall is removed
to fully exteriorise the attic.
5. Facial ridge is lowered.
6. Mastoid cavity is smoothened with polishing burr,
removing any overhangs and then irrigated with
normal saline.
7. Reconstruction of hearing mechanism. Pars tensa of
tympanic membrane and middle ear, if healthy, are left
undisturbed. If disease extends into middle ear, only
the irreversible tissues are removed. Reconstruction
of tympanic membrane or ossicular chain, if damaged,
can also be done (mastoidectomy with tympanoplasty
operation) .
8. Meatoplasty and closure of wound is same as in
radica l mastoidectomy.
Post-operative Care and Complications
Same as in radical mastoidectomy.
Mastoid Surgery
Myringoplasty
It is an operation in which reconstructive procedure is
limited to repair of tympanic membrane perforation.
Tympanoplasty without Mastoidectomy
(tympanum = middle ear)
It is an operation to eradicate disease in the middle ear
and to reconstruct the hearing mechanism without mastoid
surgery, with or without tympanic membrane grafting.
This means ossicular reconstruction only or ossicular
reconstruction with myringoplasty.
Tympanoplasty with Mastoidectomy
It is an operation to eradicate disease in both the mastoid
and middle 'ear cavity, and to reconstruct the hearing
mechanism with or without tympanic membrane grafting.
Cortical Mastoidectomy (Simple
Mastoidectomy or Schwartz Operation)
It is an exenteration of all accessible mastoid air cells preserving
the posterior meatal wall.
Modified Radical Mastoidectomy
It is an operation to eradicate disease of the attic and mastoid,
both of which are exteriorised into the external auditory
canal by removal of the posterior meatal and lateral
attic walls. Tympanic membrane remnant, functioning
ossicles and the reversible mucosa and function of the
eustachian tube are preserved. These structures are necessary
to reconstruct hearing mechanism at the time of surgery
or in a 2nd stage operation.
Radical Mastoidectomy
It is an operation to eradicate disease of the middle ear
and mastoid in which mastoid, midd le ear, attic and the
antrum are exteriorised into the external ear by removal
of posterior meatal wall. All remnants of tympanic membrane,
malleus, incus (not the stapes) chorda tympani and
the mucoperiosteal lining are removed, and the opening
of eustachian tube closed by packing a piece of muscle or
cartilage into the eustachian tube.
Meatoplasty
Meatoplasty is an operation in which a crescent of concha 1
cartilage is excised to widen the meatus. It is invariably
combined with all canal wall down procedures, i.e. modified
radical for periodic cleaning or inspection, and radical
mastoidectomies for easy access to the mastoid cavity, or it
is done as an isolated procedure in a sagging auricle seen in
older people. Sagging auricle obstructs the ear canal and
causes hearing loss and retention of wax.
Mastoid Obliteration
It is an operation to eradicate mastoid disease, when
present, and to obliterate the mastoid cavity.
Obliteration of mastoid cavity is done with pedicled temporalis
muscle or musculofascial tissue raised as flaps.
SURGICAL APPROACHES TO THE
EAR AND INCISIONS
1. Endomeatal or transcanal approach. It is used to
raise a tympanomeatal flap in order to expose the middle
ear. Rosen's incision is the most commonly used for
stapedectomy. It requires the meatus and canal to be wide
enough to work. It consists of two parts; (a) a small vertical
incision at 12 o'clock position near the annulus and (b) a
curvilinear incision starting at 6 o'clock position to meet
the 1st incision in the posterosuperior region of the canals,
5-7 mm away from the annulus (Fig. 76.1) Posterior
meatal canal skin is raised in continuity with tympanic
membrane, after dislocating the annulus from the sulcus. It
gives a good view of the middle ear and ossicles. Stapes, if
still covered by posterosuperior overhang of bony meatus,
can be exposed by removing this part of the overhang. This
incision is also used commonly for exploratory tympanotomy
to find cause for conductive hearing loss, inlay
myringoplasty or ossicular reconstruction.2. Endaural approach. It is used for:
(a) Excision of osteomas or exostosis of ear canal.
(b) Large tympanic membrane perforations.
(c) Attic cholesteatomas with limited extension into
the antrum.
(d) Modified radical mastoidectomy where disease is
limited to attic, antrum, and part of mastoid.
Endaural approach is made through Lempert's incision
(Fig. 76.2). It consists of 2 parts:
Lempert I-It is semicircular incision, made from 12
o'clock to 6 o'clock position in the posterior meatal wall
at the bony-cartilaginous junction.Lempert II-Starts from the 1st incision at 12 o'clock
and then passes upwards in a curvilinear fashion between
tragus and the crus of helix. It passes through the incisura
terminalis and thus does not cut the cartilage. Both mastoid
and external canal surgery can be done.
3. Postaural (or Wilde's) incision (Fig. 76.3). It starts
at the highest attachment of the pinna, follows the curve
of retroauricular groove, lying 1 cm behind it, and ends at
the mastoid tip. In infants and children up to 2 years of age,
the mastoid process is not developed and the facial nerve
lies exposed near its exit, and the incision therefore is slanting
posteriorly, avoiding lower part of the mastoid. Some
surgeons prefer to make the postaural incision in the sulcus
(retroauricular groove) . Postaural incision is used for:
(i) Cortical mastoidectomy.
(ii) Modified radical and radical mastoidectomy.
(iii) Tympanoplasty: when perforation extends anterior
to handle of malleus.
(iv) Exposure of CN VII in vertical segment.
(v) Surgery of endolymphatic sac.
CORTICAL MASTOIDECTOMY
Cortical mastoidectomy, known as simple or complete
mastoidectomy or Schwartz operation, is complete exenteration
of all accessible mastoid air cells and converting
them into a single cavity. Posterior meatal wall is left
intact. Middle ear structures are not disturbed.
Indications
1. Acute coalescent mastoiditis.
2. Incompletely resolved acute otitis media with reservoir
sign.
3. Masked mastoiditis.
4. As an initial step to perform:
(a) endolymphatic sac surgery
(b) decompression of facial nerve
(c) translabyrinthine or retro-Iabyrinthine procedures
for acoustic neuroma.
Figure 76.4 shows the various structures and landmarks
seen after cortical mastoidectomy.
Anaesthesia
General anaesthesia.
Position
Patient lies supine with face turned to one side and the
ear to be operated upper-most.
Steps of Operation
1. Incision. A curved postaural incision about 1 em
behind but parallel to the retroauricular sulcus, starting
at the highest attachment of pinna to the mastoid tip
(Fig. 76.3B).In infants and children up to 2 years, the incision is
short and more horizontal. This is to avoid cutting facial
nerve which is superficial in the lower part of mastoid
(Fig. 76.3C).
Incision cuts through soft tissues up to the periosteum.
Temporalis muscle is not cut in the incision.
2. Exposure of lateral surface of mastoid and
MacEwen's triangle. Periosteum is incised in the line of
first incision. A horizontal incision may be made along
the lower border of temporalis muscle for more exposure.
Periosteum is scraped from the surface of mastoid and
posterosuperior margin of osseous meatus. Tendinous
fibres of sternomastoid are sharply cut and scraped down.
A self-retaining mastoid retractor is applied.
3. Removal. of mastoid cortex and exposure of
antrum. Mastoid cortex is removed with burr, or gouge
and hammer. Mastoid antrum is exposed in the area of
suprameatal triangle (MacEwen's triangle). In an adult,
antrum lies 12-15 mm from the surface. Horizontal semicircular
canal is identified.
4. Removal of mastoid air cells. All accessible mastoid
air cells are removed leaving behind the bony plate
of tegmen tympani above, sinus plate behind and posterior
meatal wall in front.
5. Removal of mastoid tip and finishing the cavity.
Lateral wall of the mastoid tip is removed, exposing muscle
fibres of posterior belly of digastric. Zygomatic cells situated
in the root of zygoma, retrosinus cells lying between
sinus plate and cortex, behind the sinus, are removed. A
finished cavity should have bevelled edges so that soft
tissue can easily sit in and obliterate the cavity.
6. Closure of wound. MastoiJ cavity is thoroughly
irrigated with saline to remove bone dust, and the wound
is closed in two layers. A rubber drain may be left at the
lower end of incision for 24-48 hours in case of infection
or excessive bleeding. A meatal pack should be kept to
avoid stenosis of ear canal. Mastoid dressing is applied .
Post-operative Care
1. Antibiotics started pre-operatively are continued
post-operatively for at least one week. Culture swab
taken from the mastoid, during operation, may dictate
a change in the antibiotic.
2. Drain, if put, is removed in 24-48 hours and sterile
dressing done.
3. Stitches are removed on the 6th day.
Complications
1. Injury to facial nerve .
2. Dislocation of incus.
3. Injury to horizontal semicircular canal. Patient will
have post-operative giddiness and nystagmus.
4. Injury to sigmoid sinus with profuse bleeding.
5. Injury to dura of middle cranial fossa.
6. Post-operative wound infection and wound
break-down.
It is an operation in which reconstructive procedure is
limited to repair of tympanic membrane perforation.
Tympanoplasty without Mastoidectomy
(tympanum = middle ear)
It is an operation to eradicate disease in the middle ear
and to reconstruct the hearing mechanism without mastoid
surgery, with or without tympanic membrane grafting.
This means ossicular reconstruction only or ossicular
reconstruction with myringoplasty.
Tympanoplasty with Mastoidectomy
It is an operation to eradicate disease in both the mastoid
and middle 'ear cavity, and to reconstruct the hearing
mechanism with or without tympanic membrane grafting.
Cortical Mastoidectomy (Simple
Mastoidectomy or Schwartz Operation)
It is an exenteration of all accessible mastoid air cells preserving
the posterior meatal wall.
Modified Radical Mastoidectomy
It is an operation to eradicate disease of the attic and mastoid,
both of which are exteriorised into the external auditory
canal by removal of the posterior meatal and lateral
attic walls. Tympanic membrane remnant, functioning
ossicles and the reversible mucosa and function of the
eustachian tube are preserved. These structures are necessary
to reconstruct hearing mechanism at the time of surgery
or in a 2nd stage operation.
Radical Mastoidectomy
It is an operation to eradicate disease of the middle ear
and mastoid in which mastoid, midd le ear, attic and the
antrum are exteriorised into the external ear by removal
of posterior meatal wall. All remnants of tympanic membrane,
malleus, incus (not the stapes) chorda tympani and
the mucoperiosteal lining are removed, and the opening
of eustachian tube closed by packing a piece of muscle or
cartilage into the eustachian tube.
Meatoplasty
Meatoplasty is an operation in which a crescent of concha 1
cartilage is excised to widen the meatus. It is invariably
combined with all canal wall down procedures, i.e. modified
radical for periodic cleaning or inspection, and radical
mastoidectomies for easy access to the mastoid cavity, or it
is done as an isolated procedure in a sagging auricle seen in
older people. Sagging auricle obstructs the ear canal and
causes hearing loss and retention of wax.
Mastoid Obliteration
It is an operation to eradicate mastoid disease, when
present, and to obliterate the mastoid cavity.
Obliteration of mastoid cavity is done with pedicled temporalis
muscle or musculofascial tissue raised as flaps.
SURGICAL APPROACHES TO THE
EAR AND INCISIONS
1. Endomeatal or transcanal approach. It is used to
raise a tympanomeatal flap in order to expose the middle
ear. Rosen's incision is the most commonly used for
stapedectomy. It requires the meatus and canal to be wide
enough to work. It consists of two parts; (a) a small vertical
incision at 12 o'clock position near the annulus and (b) a
curvilinear incision starting at 6 o'clock position to meet
the 1st incision in the posterosuperior region of the canals,
5-7 mm away from the annulus (Fig. 76.1) Posterior
meatal canal skin is raised in continuity with tympanic
membrane, after dislocating the annulus from the sulcus. It
gives a good view of the middle ear and ossicles. Stapes, if
still covered by posterosuperior overhang of bony meatus,
can be exposed by removing this part of the overhang. This
incision is also used commonly for exploratory tympanotomy
to find cause for conductive hearing loss, inlay
myringoplasty or ossicular reconstruction.2. Endaural approach. It is used for:
(a) Excision of osteomas or exostosis of ear canal.
(b) Large tympanic membrane perforations.
(c) Attic cholesteatomas with limited extension into
the antrum.
(d) Modified radical mastoidectomy where disease is
limited to attic, antrum, and part of mastoid.
Endaural approach is made through Lempert's incision
(Fig. 76.2). It consists of 2 parts:
Lempert I-It is semicircular incision, made from 12
o'clock to 6 o'clock position in the posterior meatal wall
at the bony-cartilaginous junction.Lempert II-Starts from the 1st incision at 12 o'clock
and then passes upwards in a curvilinear fashion between
tragus and the crus of helix. It passes through the incisura
terminalis and thus does not cut the cartilage. Both mastoid
and external canal surgery can be done.
3. Postaural (or Wilde's) incision (Fig. 76.3). It starts
at the highest attachment of the pinna, follows the curve
of retroauricular groove, lying 1 cm behind it, and ends at
the mastoid tip. In infants and children up to 2 years of age,
the mastoid process is not developed and the facial nerve
lies exposed near its exit, and the incision therefore is slanting
posteriorly, avoiding lower part of the mastoid. Some
surgeons prefer to make the postaural incision in the sulcus
(retroauricular groove) . Postaural incision is used for:
(i) Cortical mastoidectomy.
(ii) Modified radical and radical mastoidectomy.
(iii) Tympanoplasty: when perforation extends anterior
to handle of malleus.
(iv) Exposure of CN VII in vertical segment.
(v) Surgery of endolymphatic sac.
CORTICAL MASTOIDECTOMY
Cortical mastoidectomy, known as simple or complete
mastoidectomy or Schwartz operation, is complete exenteration
of all accessible mastoid air cells and converting
them into a single cavity. Posterior meatal wall is left
intact. Middle ear structures are not disturbed.
Indications
1. Acute coalescent mastoiditis.
2. Incompletely resolved acute otitis media with reservoir
sign.
3. Masked mastoiditis.
4. As an initial step to perform:
(a) endolymphatic sac surgery
(b) decompression of facial nerve
(c) translabyrinthine or retro-Iabyrinthine procedures
for acoustic neuroma.
Figure 76.4 shows the various structures and landmarks
seen after cortical mastoidectomy.
Anaesthesia
General anaesthesia.
Position
Patient lies supine with face turned to one side and the
ear to be operated upper-most.
Steps of Operation
1. Incision. A curved postaural incision about 1 em
behind but parallel to the retroauricular sulcus, starting
at the highest attachment of pinna to the mastoid tip
(Fig. 76.3B).In infants and children up to 2 years, the incision is
short and more horizontal. This is to avoid cutting facial
nerve which is superficial in the lower part of mastoid
(Fig. 76.3C).
Incision cuts through soft tissues up to the periosteum.
Temporalis muscle is not cut in the incision.
2. Exposure of lateral surface of mastoid and
MacEwen's triangle. Periosteum is incised in the line of
first incision. A horizontal incision may be made along
the lower border of temporalis muscle for more exposure.
Periosteum is scraped from the surface of mastoid and
posterosuperior margin of osseous meatus. Tendinous
fibres of sternomastoid are sharply cut and scraped down.
A self-retaining mastoid retractor is applied.
3. Removal. of mastoid cortex and exposure of
antrum. Mastoid cortex is removed with burr, or gouge
and hammer. Mastoid antrum is exposed in the area of
suprameatal triangle (MacEwen's triangle). In an adult,
antrum lies 12-15 mm from the surface. Horizontal semicircular
canal is identified.
4. Removal of mastoid air cells. All accessible mastoid
air cells are removed leaving behind the bony plate
of tegmen tympani above, sinus plate behind and posterior
meatal wall in front.
5. Removal of mastoid tip and finishing the cavity.
Lateral wall of the mastoid tip is removed, exposing muscle
fibres of posterior belly of digastric. Zygomatic cells situated
in the root of zygoma, retrosinus cells lying between
sinus plate and cortex, behind the sinus, are removed. A
finished cavity should have bevelled edges so that soft
tissue can easily sit in and obliterate the cavity.
6. Closure of wound. MastoiJ cavity is thoroughly
irrigated with saline to remove bone dust, and the wound
is closed in two layers. A rubber drain may be left at the
lower end of incision for 24-48 hours in case of infection
or excessive bleeding. A meatal pack should be kept to
avoid stenosis of ear canal. Mastoid dressing is applied .
Post-operative Care
1. Antibiotics started pre-operatively are continued
post-operatively for at least one week. Culture swab
taken from the mastoid, during operation, may dictate
a change in the antibiotic.
2. Drain, if put, is removed in 24-48 hours and sterile
dressing done.
3. Stitches are removed on the 6th day.
Complications
1. Injury to facial nerve .
2. Dislocation of incus.
3. Injury to horizontal semicircular canal. Patient will
have post-operative giddiness and nystagmus.
4. Injury to sigmoid sinus with profuse bleeding.
5. Injury to dura of middle cranial fossa.
6. Post-operative wound infection and wound
break-down.
Myringotomy
It is incision of the tympanic membrane with the purpose
to drain suppurative or nonsuppurative effusion of the
middle ear or to provide aeration in case of malfunctioning
eustachian tube. Ventilation tube (grommet) may
also be required in the latter case.
Indications
1. Acute suppurative otitis media
(a) Severe earache with bulging tympanic membrane.
(b) Incomplete resolution with opaque drum and
persistent conductive deafness.
(c) Complications of acute otitis media, e.g. facial
paralysis, labyrinthitis or meningitis with bulging
tympanic membrane.
2. Serous otitis media.
3. Aero-otitis media (to drain fluid and "unlock" the
eustachian tube).
4. Atelectatic ear (grommet is often inserted for long-term
aeration).
Contraindications
Suspected intratympanic glomus tumour. Myringotomy
in these cases can cause profuse bleeding. Tympanotomy
is preferred.
Anaesthesia
In infants and children, always use general anaesthesia. For
adults, general anaesthesia is used only when tympanic
membrane is acutely inflamed. If there is no inflammation,
myringotomy can be done under local anaesthesia or no
anaesthesia at all.
Steps of Operation
1. Ear canal is cleaned of wax and debris.
2. Operation is ideally performed under operating microscope
using a sharp myringotome and a good suction
apparatus.
3. In acute suppurative otitis media, a circumferential
incision is made in the posteroinferior quadrant of
tympanic membrane, midway between hundle uf
malleus and tympanic annulus, avoiding injury to
incudostapedial joint (Fig. 75.lA).
4. In serous otitis media, a small radial incision is given
in the posteroinferior or anteroinferior quadrant and
all the effusion sucked out (Fig. 75.1B).
When ventilation tube is to be inserted, incision should
be just enough to admit the tube (Fig. 75.2).
Pitfalls of Myringotomy
1. When tympanic membrane is thick, incision may
remain only in the superficial layers of drumhead
without cutting through its entire thickness.
2. Incision in the posterior meatal wall. This may happen
when distinction between drum-head and posterior
meatal wall is lost, when both are inflamed.
Post-operative Care
Daily mopping of ear discharge will be required in cases
of acute suppurative otitis media. In serous otitis media,
just leave a wad of cotton wool for 24-48 hours.
Drum incisions usually heal rapidly. No water should
be permitted to enter the ear canal for at least one week,
and if a grommet has been inserted, entry of water is
prevented so long as grommet is in position.
Complications
1. Injury to incudostapedial joint or stapes.
2. Injury to jugular bulb with profuse bleeding, if jugular
bulb is high and floor of the middle ear dehiscent.
3. Middle ear infection.
to drain suppurative or nonsuppurative effusion of the
middle ear or to provide aeration in case of malfunctioning
eustachian tube. Ventilation tube (grommet) may
also be required in the latter case.
Indications
1. Acute suppurative otitis media
(a) Severe earache with bulging tympanic membrane.
(b) Incomplete resolution with opaque drum and
persistent conductive deafness.
(c) Complications of acute otitis media, e.g. facial
paralysis, labyrinthitis or meningitis with bulging
tympanic membrane.
2. Serous otitis media.
3. Aero-otitis media (to drain fluid and "unlock" the
eustachian tube).
4. Atelectatic ear (grommet is often inserted for long-term
aeration).
Contraindications
Suspected intratympanic glomus tumour. Myringotomy
in these cases can cause profuse bleeding. Tympanotomy
is preferred.
Anaesthesia
In infants and children, always use general anaesthesia. For
adults, general anaesthesia is used only when tympanic
membrane is acutely inflamed. If there is no inflammation,
myringotomy can be done under local anaesthesia or no
anaesthesia at all.
Steps of Operation
1. Ear canal is cleaned of wax and debris.
2. Operation is ideally performed under operating microscope
using a sharp myringotome and a good suction
apparatus.
3. In acute suppurative otitis media, a circumferential
incision is made in the posteroinferior quadrant of
tympanic membrane, midway between hundle uf
malleus and tympanic annulus, avoiding injury to
incudostapedial joint (Fig. 75.lA).
4. In serous otitis media, a small radial incision is given
in the posteroinferior or anteroinferior quadrant and
all the effusion sucked out (Fig. 75.1B).
When ventilation tube is to be inserted, incision should
be just enough to admit the tube (Fig. 75.2).
Pitfalls of Myringotomy
1. When tympanic membrane is thick, incision may
remain only in the superficial layers of drumhead
without cutting through its entire thickness.
2. Incision in the posterior meatal wall. This may happen
when distinction between drum-head and posterior
meatal wall is lost, when both are inflamed.
Post-operative Care
Daily mopping of ear discharge will be required in cases
of acute suppurative otitis media. In serous otitis media,
just leave a wad of cotton wool for 24-48 hours.
Drum incisions usually heal rapidly. No water should
be permitted to enter the ear canal for at least one week,
and if a grommet has been inserted, entry of water is
prevented so long as grommet is in position.
Complications
1. Injury to incudostapedial joint or stapes.
2. Injury to jugular bulb with profuse bleeding, if jugular
bulb is high and floor of the middle ear dehiscent.
3. Middle ear infection.
Subscribe to:
Posts (Atom)