Atlas of Operative Otorhinolaryngology and Head & Neck Surgery: Otology and Lateral Skullbase Surgery 9789351522164, 9789350904794, 9350904799

Citation preview

's

lil

Ja

RL

O

y ar br

Li

ATLAS OF OPERATIVE OTORHINOLARYNGOLOGY AND HEAD & NECK SURGERY

OTOLOGY AND LATERAL SKULLBASE SURGERY

Vol. 1

ATLAS OF OPERATIVE OTORHINOLARYNGOLOGY AND HEAD & NECK SURGERY

OTOLOGY AND LATERAL SKULLBASE SURGERY Editors Bachi T Hathiram Professor and Head Department of ENT and Head and Neck Surgery Topiwala National Medical College and BYL Nair Charitable Hospital Mumbai, Maharashtra, India

Vicky S Khattar Assistant Professor Department of ENT and Head and Neck Surgery Topiwala National Medical College and BYL Nair Charitable Hospital Mumbai, Maharashtra, India

Forewords Jatin P Shah Milind V Kirtane ®

JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD New Delhi • London • Philadelphia • Panama

Vol. 1

®

Jaypee Brothers Medical Publishers (P) Ltd Headquarters Jaypee Brothers Medical Publishers (P) Ltd 4838/24, Ansari Road, Daryaganj New Delhi 110 002, India Phone: +91-11-43574357 Fax: +91-11-43574314 Email: [email protected] Overseas Offices J.P. Medical Ltd Jaypee-Highlights Medical Publishers Inc. 83, Victoria Street, London City of Knowledge, Bld. 237, Clayton SW1H 0HW (UK) Panama City, Panama Phone: +44-2031708910 Phone: +507-301-0496 Fax: +02-03-0086180 Fax: +507-301-0499 Email: [email protected] Email: [email protected] Jaypee Brothers Medical Publishers (P) Ltd 17/1-B Babar Road, Block-B Shaymali, Mohammadpur Dhaka-1207, Bangladesh Mobile: +08801912003485 Email: [email protected]

Jaypee Brothers Medical Publishers Ltd The Bourse 111 South Independence Mall East Suite 835, Philadelphia, Pennsylvania, USA 19106, USA Phone: + 267-519-9789 Email: [email protected]

Jaypee Brothers Medical Publishers (P) Ltd Shorakhute, Kathmandu Nepal Phone: +00977-9841528578 Email: [email protected]

Website: www.jaypeebrothers.com Website: www.jaypeedigital.com © 2013, Jaypee Brothers Medical Publishers All rights reserved. No part of this book may be reproduced in any form or by any means without the prior permission of the publisher. Inquiries for bulk sales may be solicited at: [email protected]

This book has been published in good faith that the contents provided by the contributors contained herein are original, and is intended for educational purposes only. While every effort is made to ensure accuracy of information, the publisher and the editors specifically disclaim any damage, liability, or loss incurred, directly or indirectly, from the use or application of any of the contents of this work. If not specifically stated, all figures and tables are courtesy of the editors. Where appropriate, the readers should consult with a specialist or contact the manufacturer of the drug or device. Atlas of Operative Otorhinolaryngology and Head & Neck Surgery: Otology and Lateral Skullbase Surgery (Vol. 1) First Edition: 2013

ISBN 978-93-5090-479-4 Printed at:

Dedicated to

Shri Swami Samarth My father, Adi Dinshaw Mistry—Who taught me the value of hard work and loyalty My mother, Viloo Adi Mistry—For her selfless love and caring Both my parents and mamma—For their blessings and encouragement My husband, Tempton—Always loving, caring and encouraging My miracle and happiness, Karishma and Khushi—For making life worthwhile Rustom, Khushru, Firozee, Sharon, Jenaifer, Zenia, Travis and Hazel—For believing in me and being with me Bachi T Hathiram My father, Subhash Chandra Gyanchand Khattar—My support My mother, Veena Subhash Khattar—My encouragement My grandparents, Gyanchand Khattar, Mohandevi Khattar, Vas Dev Pawa, Tulsidevi Pawa—Who indulged me Shalu, Sameer, Sehar and Sia—My indulgence My family, friends, teachers and students Vicky S Khattar

Contributors Ahmad Abu-Omar DOHNS MRCS Educational Fellow in Otolaryngology Whipps Cross University Hospital London, UK Bashar Abuzayed MD Attending Neurosurgeron Department of Neurosurgery Cerrahpasa Medical Faculty Istanbul University Istanbul, Turkey Rahul Agrawal Department of ENT and Skull Base Surgery Dr Balabhai Nanavati Hospital Mumbai, Maharashtra India Vikas Agrawal MS FCPS DORL Consultant ENT Surgeon Speciality ENT Hospital, Kandivli Asian Heart Institue, Bandra Sevenhills Hospital, Andheri BSES MG Hospital, Andheri Mumbai, Maharashtra India RG Aiyer Professor and Head Department of ENT and Head and Neck Surgery Govt Medical College and SSG Hospital Vadodara, Gujarat, India KM Ajith Department of ENT SS Institute of Medical Sciences and Research Center Davangere, Karnataka India

Lynzee N Alworth PhD AuD CCC-A F/AAA

Assistant Professor of Audiology University Audiology Associates University of Louisville Kentucky, USA Danic Hadzibegovic Ana MD Department of Otorhinolaryngology and Maxillofacial Surgery Medical School Osijek, University Josip Juraj Strossmayer of Osijek Croatia Miroslav Andrić DDS Msc Clinic of Oral Surgery School of Dentistry University of Belgrade Belgrade, Serbia Nebil Ark Fatih University, Faculty of Medicine Department of Otorhinolaryngology Head and Neck Surgery Ankara, Turkey V Arora Associate Professor Department of ENT and Head Neck Surgery University College of Medical Sciences and GTB Hospital New Delhi, India Katie L Austin AuD CCC-A F/AAA Audiologist Heuser Hearing Institute, and Heuser Speech and Language Academy Louisville Kentucky, USA

Luca Autelitano MD Maxillo-Facial Surgeon Smile House, San Paolo Hospital University of Milan, via A. di Rudinì Milan, Italy Gregor Bachmann-Harildstad MD PhD Akershus University Hospital/UIO Otorhinolaryngology Nordbyhagen, Norway Vincent Bachy Departement de Chirurgie ORL et Chirurgie Cervico-Faciale Site Mont-Godinne: Avenue Docteur G Thérasse Yvoir, Belgium Mohamed Badr-El-Dine MD Professor of Otolaryngology Consultant Otology Neurotology and Skull Base Surgery Faculty of Medicine University of Alexandria, Egypt President of the Egyptian Society of Skull Base Surgery Egypt Yogesh Bajaj MS MD FRCS (ORL HNS) Consultant ENT Barts Children’s Hospital and Royal London Hospitals Honorary Lecturer Anglia Ruskin University London, UK Karthikeyan Balasubramanian Department of Surgical Oncology Prince Aly Khan Hospital Mumbai, Maharashtra, India

viii Otology and Lateral Skullbase Surgery Maurizio Barbara ENT Clinic, Sant’Andrea Hospital Sapienza University Rome, Italy Brajendra Baser MS (AIIMS) DNB Professor and Head of ENT Shri Aurbindo Institute of Medical Sciences (SAIMS Medical College) Director Akash Hospital Indore, Madhya Pradesh India BP Belaldavar Department of ENT, KLE University’s JN Medical College and Consultant ENT Surgeon, KLES Dr Prabhakar Kore Hospital Belgaum, Karnataka, India Michael S Benninger MD Chairman, Head and Neck Institute The Cleveland Clinic Professor of Surgery The Learner School of Medicine of Case Western Reserve University Euclid Avenue Cleveland, Ohio, USA Abir K Bhattacharyya

MS DNB FRCS



FRCS(ORL) FACS

Consultant Otolaryngologist and Head and Neck Surgeon Associate Director of Medical Education (Surgery) and Royal College Surgical Tutor Whipps Cross University Hospital London, UK Merill Biel Department of Otolaryngology University of Minnesota Minneapolis Minnesota, USA

Kofi DO Boahene Assistant Professor Facial Plastic and Reconstructive Surgery Johns Hopkins Facial Plastic and Reconstructive Surgery Center Minimally Invasive Skullbase Surgery Microvascular Surgery Department of Otolaryngology Head and Neck Surgery Johns Hopkins Medical Institute, USA Miriam Boenisch MD PhD Medicent Linz, Untere Donaulände Linz, Austria Mariano M Boglione MD Pediatric Surgeon General Pediatric Surgery Division Chief of Lung Transplant Program Hospital de Pediatría Prof Dr Juan P Garrahan Buenos Aires, Argentina Luis A B Borba MD PhD Professor Chief of the Neurosurgical Department Evangelic Universitary Hospital Curitiba, Paraná, Brazil. Neurosurgeon of the Brain and Heart Institute Curitiba, Paraná, Brazil Jennings R Boyette MD Department of Otolaryngology— Head and Neck Surgery University of Arkansas for Medical Sciences Arkansas Children’s Hospital Little Rock, Arkansas, USA Ryan F Brown MD Department of Head and Neck Surgery Kaiser Permanente Denver Colorado, USA

James A Burns Massachusetts General Hospital Division of Laryngeal Surgery Boston, Massachusetts, USA Giulia Carnevali MD Maxillo-Facial Surgeon Department of Traumatology and Maxillo Facial Surgery AOUC Hospital and University of Florence Largo Palagi Florence, Italy Giorgio Carrabba MD PhD Neurosurgery Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico University of Milano Milano, Italy Ricardo L Carrau MD FACS Professor Department of Otolaryngology Head and Neck Surgery The Ohio State University Medical Center West 10th Avenue Cramblett Hall, Columbus Ohio, USA Ali Diaz Castillejos Fellow of Cranial Base Surgery Evangelic Universitary Hospital Curitiba, Paraná – Brazil CW David Chang MD Associate Clinical Professor, Facial Plastic and Reconstructive Surgery Residency Program Director Department of Otolaryngology Head and Neck Surgery University of Missouri One Hospital Drive Columbia Missouri, USA

Contributors ix Dinesh K Chhetri MD University of California— Los Angeles Department of Head and Neck Surgery CHS 62-132, UCLA School of Medicine Los Angeles California, USA

Rajib Dasgupta London, UK

Chi-Yee Choi Division of Head and Neck Reconstruction Surgery Department of Surgery United Christian Hospital Hong Kong SAR, China

Matteo de Notaris MD PhD Department of Neurosurgery Hospital Clinic, Faculty of Medicine Universitat de Barcelona Laboratory of Surgical Neuroanatomy (LSNA) Faculty of Medicine Universitat de Barcelona Barcelona, Spain

Tam-Lin Chow Division of Head and Neck Reconstruction Surgery Department of Surgery United Christian Hospital Hong Kong SAR, China Yakup Cil MD Plastic Surgeon Eskisehir Military Hospital Department of Plastic Surgery Eskisehir, Turkey Joseph Curry Department of Otolaryngology Head and Neck Surgery University of Miami Miller School of Medicine, Miami Florida, USA Sanket Dani Resident—Department of ENT and Head and Neck Surgery TN Medical College and BYL Nair Charitable Hospital Mumbai, Maharashtra, India

Danic Davorin MD PhD Department of Otorhinolaryngology and Maxillofacial Surgery Medical School Osijek University Josip Juraj Strossmayer of Osijek, Croatia

Alberto Deganello MD PhD Head and Neck Surgeon Assistant Professor in Otolaryngology SOD Otolaryngology 1 Department of Surgical Sciences AOU-Careggi, University of Florence Vle Morgagni, Florence, Italy Amir R Dehdashti MD FACS Geisinger Clinic Department of Neurosurgery, USA C E Deopujari Department of Neurosurgery Bombay Hospital Mumbai, Maharashtra, India Daniel G Deschler Director Division of Head and Neck Surgery Department of Otology and Laryngology Massachusetts Eye and Ear Infirmary Associate Professor Harvard Medical School Boston, Massachusetts, USA

Akshay P Deshpande Resident, Department of Plastic Surgery TN Medical College and BYL Nair Charitable Hospital Mumbai, Maharashtra, India Snigdha Devane Resident—Department of ENT and Head and Neck Surgery, TN Medical College and BYL Nair Charitable Hospital Mumbai, Maharashtra, India PV Dhond MS (ENT) DORL Honorary Consultant Bhagwati Hospital Mumbai, Maharashtra, India Sara R Dickie MD Section of Plastic and Reconstructive Surgery University of Chicago Department of Surgery Chicago, Illinois, USA J Dings Department of Neurosurgery Maastricht University Medical Center The Netherlands Gilles Dolivet MD PhD Head and Neck Surgeon Otolaryngologist Head of the Surgical Oncology Department National Cancer Institute “Alexis Vautrin” Av. de Bourgogne Vandoeuvre-Les-Nancy University of Nancy France Adam Donne Consultant in Paediatric Otolaryngology Alder Hey Children’s Hospital Liverpool, UK

x Otology and Lateral Skullbase Surgery Mark Domanski Department of Otolaryngology— Head and Neck Surgery The George Washington University USA Prgomet Drago Clinics of Otorhinolaryngology Head and Neck Surgery Clinical Hospital Centar Zagreb Medical School Zagreb University of Zagreb, Croatia Yadranko Ducic MD FACS FRCS Clinical Professor Department of Otolaryngology— Head and Neck Surgery at the University of Texas Southwestern Medical Center, Dallas Texas Baylor Neuroscience Skullbase Program Dallas Fort Worth Texas Otolaryngology and Facial Plastic Surgery Associates Fort Worth Texas, USA Jason Durel Resident Physician Department of Otolaryngology— Head and Neck Surgery Louisiana State University Health Sciences Center New Orleans, Louisiana, USA Philippe Eloy Department of Otorhinolaryngology University of Louvain (Belgium) Cliniques de Mont Godinne (Yvoir) Av Therasse Yvoir, Belgium Joaquim Enseñat MD PhD Department of Neurosurgery Hospital Clinic, Faculty of Medicine Universitat de Barcelona Barcelona, Spain

Audrey B Erman Department of Otology and Laryngology Massachusetts Eye and Ear Infirmary Harvard Medical School Boston, Massachusetts, USA Waleed F Ezzat Professor of Otolaryngology Head and Neck Surgery Ain- Shams University Cairo, Egypt Leo FS Ditzel Filho Research Fellows Department of Neurological Surgery The Ohio State University Columbus, USA Dan M Fliss MD Professor and Chairman Department Otolaryngology Head and Neck Surgery and Maxillofacial Surgery Tel-Aviv Sourasky Medical Center 6 Weizmann St, Tel-Aviv, Israel Hossam MT Foda MD Professor and Chief of Facial Plastic Surgery Otolaryngology Department Alexandria Medical School, Egypt Arun K Gadre MD FACS MS(Bom) DORL HHI Professor of Otology and Neurotology Director of Otology, Neurotology and Skull Base Surgery Associate Professor of Otolaryngology—Head and Neck Surgery Department of Surgery University of Louisville Kentucky, USA

Lorenzo Gaini Department of Otorhinolaryngology IRCCS Policlinico University of Milano-Statale Milano, Italy Oreste Gallo MD Associate Professor in Otolaryngology Head of the SOD Otolaryngology Department of Surgical Sciences AOU-Careggi University of Florence Vle Morgagni Florence, Italy Werner Garavello Department of Otorhinolaryngology San Gerardo Hospital University of Milano Bicocca Monza, Italy Celeste C Gary MD Department of Otolaryngology Head and Neck Surgery Louisiana State University Health Sciences Center 533 Bolivar Street New Orleans, Louisiana, USA Jacques Gaudet Resident Physician, Department of Otolaryngology– Head and Neck Surgery, Louisiana State University Health Sciences Center New Orleans, Louisiana, USA Panagiotis Gerbesiotis MD PhD Registrar—ENT Surgeon 2nd University Department of Otorhinolaryngology Head and Neck Surgery ATTIKON Hospital, Rimini 1 Chaidari, Athens, Greece

Contributors xi Nurperi Gazioglu MD Professor in Neurosurgery Department of Neurosurgery Cerrahpasa Medical Faculty Istanbul University Istanbul, Turkey

Arunesh Gupta Assistant Professor Department of Plastic Surgery TN Medical College and BYL Nair Charitable Hospital Mumbai, Maharashtra, India

Gianni Gitti MD PhD Otolaryngologist Centro Rieducazione Ortofonica Piazzale della Porta al Prato Florence Italy

Ashok K Gupta Professor and Head Department of Otolaryngology (Unit II) PGIMER, Chandigarh, India

Bachi T Hathiram Professor and Head Department of ENT and Head and Neck Surgery TN Medical College and BYL Nair Charitable Hospital Mumbai, Maharashtra, India

Rahul Gupta Assistant Professor Department of ENT and Head and Neck Surgery Govt. Medical College and SSG Hospital Vadodara, Gujarat, India

Biswajyoti Hazarika Senior Consultant Department of Surgical Oncology Max Cancer Center New Delhi, India

Haralampos Gouveris Department of Otorhinolaryngology The University of Mainz Hospitals and Clinics Langenbeckstr, Mainz, Germany Cassio Zottis Grapiglia MD Fellow of Cranial Base Surgery Evangelic Universitary Hospital Curitiba, Paraná – Brazil Jorge Orlando Guerrissi Head, Department of Plastic and Reconstructive Surgery Head and Neck Surgery Argerich Hospital Health Ministery of Ciudad Autonoma de Buenos Aires Argentina

Mehmet Habesoglu Department of II-Otolaryngology— Head and Neck Surgery Haydarpasa Numune Education and Research Hospital, Turkey Tulay Erden Habesoglu Department of II-Otolaryngology— Head and Neck Surgery Haydarpasa Numune Education and Research Hospital, Turkey

Anish K Gupta Sr Consultant Department of ENT Fortis Hospital Mohali Punjab, India

Josef Haik MD MPH Assistant Professor of Plastic Surgery; Deputy of the Division of Plastic and Reconstructive Surgery Director of the Intensive Care Burn Unit Sheba Medical Center Tel-Aviv University Ramat Gan, Israel

Anuragini Gupta Jr Resident Department of ENT Resident BSPH Bhilai Chattisgarh, India

Arsheed Hussain Hakeem Consultant Department of Head and Neck Surgery and Surgical Oncology Prince Aly Khan Hospital Mumbai, Maharashtra, India

Imtiyaz Hussain Hakeem Resident Department of Internal Medicine Florida Hospital Medical Center Orlando, Florida, USA

Barbara Henderson Department of Biophysics/Cell Stress Biology Roswell Park Cancer Institute Buffalo, NY, USA Patrick T Hennessey MD PGY-5 Resident The Johns Hopkins Hospital Department of Otolaryngology— Head and Neck Surgery, USA Björn Herman Department of Otolaryngology University of Miami School of Medicine, USA Yasuyuki Hinohira Department of Otorhinolaryngology Showa University School of Medicine Hatanodai, Shinagawa, Tokyo, Japan Steven B Hopping Department of Otolaryngology— Head and Neck Surgery The George Washington University USA

xii Otology and Lateral Skullbase Surgery Takashi Horiguchi Associate Professor Department of Neurosurgery Keio University School of Medicine Japan K Hörmann Head and Chair of the Department of ORL and Head and Neck Surgery University Hospital of Mannheim Mannheim, Germany Gilad Horowitz Department Otolaryngology Head and Neck Surgery and Maxillofacial Surgery Tel-Aviv Sourasky Medical Center 6 Weizmann St, Tel-Aviv, Israel Sonna Ifeacho Department of Otolaryngology Great Ormond Street Hospital London, UK Shabbir Indorewala Department of Otorhinolaryngology and The Skull Base Group Dr Balabhai Nanavati Hospital Mumbai, Maharashtra, India Ankit Jain Resident—Department of ENT and Head and Neck Surgery, TN Medical College and BYL Nair Charitable Hospital Mumbai, Maharashtra, India Yong Ju Jang Professor Department of Otolaryngology Asan Medical Center University of Ulsan College of Medicine, Seoul, Korea Sharan C Jayaram Head and Neck Fellow Department of Otolaryngology New Queen Elizabeth Hospital Birmingham, UK

Narayan Jayashankar Department of Otorhinolaryngology and the Skull Base Group Department of ENT and Skull Base Surgery Dr Balabhai Nanavati Hospital Mumbai, Maharashtra, India Deya Jourdy Department of Otolaryngology University of Miami School of Medicine, USA Javier Herrero Jover MD PhD Plastic Surgery Department Centro Medico TEKNON Vilana, Barcelona, Spain Akinobu Kakigi MD Assistant Professor Department of Otolaryngology Head and Neck Surgery Faculty of Medicine Tokyo University, Japan Mohan Kameswaran DSc MS FRCS (Ed)

FAMS FICS DLO

Consultant ENT Surgeon Department of Implant Otology Madras ENT Research Foundation Raja Annamalaipuram, Chennai Tamil Nadu, India Tolga Kandogan MD Associate Professor of Otolaryngology Head and Neck Surgery Izmir Bozyaka Teaching and Research Hospital Department of Otol Aryngology Head and Neck Surgery Izmir Bozyaka, Turkey Sunita Kanojia Department of ENT Bombay Hospital Mumbai, Maharashtra, India

Gauri Kapre Consultant ENT surgeon Neeti Clinics, Nagpur Clinical Fellow Bombay Hospital Mumbai, Maharashtra, India Madan Kapre Director Neeti Clinics, Nagpur Honorary senior surgeon RST Cancer Hospital Nagpur Maharashtra, India Pornthep Kasemsiri Research Fellows Department of Otolaryngology and Head and Neck Surgery The Ohio State University Columbus, USA Amin B Kassam Professor Department of Neurological Surgery University of Ottawa Ottawa, Canada Daniel F Kelly MD Brain Tumor Center and Pituitary Disorders Program John Wayne Cancer Institute at Saint John's Health Center Santa Monica, California, USA Guy Kenyon FRCS Consultant ENT Surgeon Whipps Cross University Hospital NHS Trust 69 Harley Street London, UK Vicky S Khattar Assistant Professor Department of ENT and Head and Neck Surgery TN Medical College and BYL Nair Charitable Hospital Mumbai, Maharashtra India

Contributors xiii Sunil Khot Resident—Department of ENT and Head and Neck Surgery TN Medical College and BYL Nair Charitable Hospital Mumbai, Maharashtra, India Ji Heui Kim Department of Otolaryngology Asan Medical Center University of Ulsan College of Medicine Seoul, Korea

Murat Küçüktaş MD Departments of Dermatology Nevşehir State Hospital Nevşehir, Turkey Melda Kunduk Assistant Professor Department of Otolaryngology— Head and Neck Surgery Louisiana State University Health Science Center New Orleans Louisiana, USA

Milind Kirtane Professor Emeritus Seth GS Medical College Hon Surgeon at KEM Hospital Hon Consulting ENT Surgeon at PD Hinduja National Hospital Hon ENT Consultant to his Excellency the Governor of Maharashtra Hon ENT Consultant at Prince Aly Khan Hospital Mumbai, Maharashtra, India

Daniel B Kuriloff MD FACS Director Center for Thyroid and Parathyroid Surgery New York Head and Neck Institute Lenox Hill Hospital Associate Professor Clinical Otolaryngology Head and Neck Surgery Columbia University 110 East 59th Street New York, NY, USA

Janusz Klatka Department of Otolaryngology and Laryngeal Oncology Medical University of Lublin Poland

Balagopal Kurup Resident Department of ENT and Head and Neck Surgery TN Medical College and BYL Nair Charitable Hospital Mumbai, Maharashtra, India

Masahiro Komori Department of Otolaryngology Head and Neck Surgery Kochi Medical School Okatoyo, Nankoku Kochi, Japan Shenal Kothari MS Associate Professor of ENT Department of ENT SAIMS Medical College Indore, Madhya Pradesh, India

Zekayi Kutlubay MD Departments of Dermatology İstanbul University Cerrahpaşa Medical Faculty, İstanbul, Turkey Danielle de Lara Research Fellows Department of Neurological Surgery The Ohio State University Columbus, USA

Guglielmo Larotonda MD Resident in Otolaryngology, SOD Otolaryngology 1 Department of Surgical Sciences AOU-Careggi, University of Florence Vle Morgagni, Florence, Italy Georges Lawson Otolaryngology Head and Neck Surgery Department Louvain University Hospital of ­Mont-Godinne, Yvoir, Belgium Davide Lazzeri MD Plastic Surgeon Plastic and Reconstructive Surgery Unit, Santa Chiara Hospital of Pisa Via Roma Pisa, Italy Eugenijus Lesinskas MD PhD Clinic of Ear, Nose Throat and Eye Diseases Medical Faculty Vilnius University, Lithuania Andreas Leunig Professor Dr. Med. Andreas Leunig HNO-Zentrum Starnberg Prinzenweg 1 Starnberg, Germany Roman Liscak Na Homolce Hospital Prague, Czech Republic Marco Locatelli MD PhD Neurosurgery, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, University of Milano, Milano, Italy Kevin Lollar MD Private Practice Hannibal, Missouri, USA

xiv Otology and Lateral Skullbase Surgery Jennifer L Long MD PhD University of California-Los Angeles Department of Head and Neck Surgery UCLA School of Medicine Los Angeles, California, USA Claudio Macrì ENT Clinic, Sant’Andrea Hospital Sapienza University Rome, Italy Vishal Madan MBBS (Hons) MD MRCP Consultant Dermatologist Laser and Dermatological Surgeon Salford Royal NHS Foundation Trust Stott Lane Salford, Manchester, UK Amit Magadum Resident—Department of Anatomy JN Medical College Belgaum, Karnataka, India Dipesh J Malviya Resident—Department of Plastic Surgery, TN Medical College and BYL Nair Charitable Hospital Mumbai, Maharashtra, India Jaiganesh Manickavasagam FRCS (ORL-HNS)

Royal Hallamshire Hospital Sheffield, UK Gauri Mankekar ENT Consultant PD Hinduja Hospital Mahim, Mumbai, Maharashtra, India Wolf J Mann Department of Otorhinolaryngology The University of Mainz Hospitals and Clinics, Mainz, Germany Alexander Margulis MD Senior Lecturer Hebrew University School of Medicine Head—Center for Pediatric and Craniofacial Plastic Surgery Hadassah Medical Center Jerusalem, Israel

Nayla Matar Otolaryngology Head and Neck Surgery Department Hôtel Dieu de France Bellevue Medical Center Saint-Joseph University Beirut, Lebanon Nancy McLaughlin USA Andrew J McWhorter Assistant Professor Director Department of Otolaryngology— Head and Neck Surgery Louisiana State University Health Sciences Center New Orleans Louisiana, USA Madhuri Mehta Department of Otorhinolaryngology and the Skull Base Group Dr Balabhai Nanavati Hospital Mumbai, Maharashtra, India Jayakumar R Menon Consultant Laryngologist, Kerala Institute of Medical Sciences Thiruvananthapuram, Kerala, India Rajendra B Metgudmath Consultant, Head and Neck Surgical Oncologist, KLES Dr Prabhakar Kore Hospital and MRC Belgaum Associate Professor Surgical Oncology (Head and Neck) JN Medical College, KLE University Belgaum, Karnataka, India Jignesh Mewa Department of Surgical Oncology Prince Aly Khan Hospital Mumbai, Maharashtra, India Julie A Miller Department of Surgery Royal Melbourne Hospital and University of Melbourne, Australia

Sonal Modi Department of Otorhinolaryngology and the Skull Base Group Dr Balabhai Nanavati Hospital Mumbai, Maharashtra, India Arash Mohebati Senior Fellow in Head and Neck Surgery Memorial Sloan Kettering Cancer Center New York, USA Aliasgar Moiyadi Associate Professor Department of Neurosurgery Tata Memorial Center Mumbai, Maharashtra, India Simonetta Monini ENT Clinic, Sant’Andrea Hospital Sapienza University Rome, Italy Eric J Moore MD Mayo Clinic Department of Otolaryngology Head and Neck Surgery 200 First Street SW Rochester, Minnesota, USA KP Morwani Department of ENT and Skull Base Surgery Dr Balabhai Nanavati Hospital Mumbai, Maharashtra, India Fabrizio Moscatiello MD PhD Plastic Surgery Department, Centro Medico TEKNON Vilana, Barcelona, Spain RS Mudhol Professor and Head, Department of ENT, KLE University’s JN Medical College and Consultant ENT surgeon, KLES Dr Prabhakar Kore Hospital Belgaum, Karnataka India

Contributors xv Rajashekhar Myageri Assistant Professor SDM Medical College Dharwad, Karnataka, India

Jerzy Nyzio MD Intensive Care Unit St John Grande’s Hospital Kraków, Poland

Lalita Naik Skull Base Surgery Team, Dr Balabhai Nanavati Hospital Mumbai, Maharashtra, India

Matthew Old Department of Otolaryngology and Head and Neck Surgery The Ohio State University Columbus, USA

Haralampos Gouveris Department of Otorhinolaryngology, The University of Mainz Hospitals and Clinics, Mainz, Germany Deepa Nair Assistant Professor Department of Head and Neck Surgical Oncology Tata Memorial Center Mumbai, Maharashtra, India Amith Naragund Assistant Professor, Department of ENT, KLE University’s JN Medical College and Consultant ENT Surgeon, KLES Dr Prabhakar Kore Hospital Belgaum, Karnataka, India Chitra Nayak Associate Professor and Head Department of Dermatology TN Medical College and BYL Nair Charitable Hospital Mumbai, Maharashtra, India Nupur Kapoor Nerurkar Laryngologist Bombay Hospital Mumbai, Maharashtra, India Thomas P Nikolopoulos Associate Professor—ENT Surgeon 2nd University Department of Otorhinolaryngology Head and Neck Surgery ATTIKON Hospital, Rimini 1, Chaidari Athens, Greece

Peter D Oliver Department of Otolaryngology Head and Neck Surgery Louisiana State University Health Sciences Center Bolivar Street New Orleans Louisiana, USA Goldan Oren MD Attending Surgeon, Division of Plastic and Reconstructive Surgery Sheba Medical Center Tel-Aviv University Ramat Gan, Israel Bradley A Otto Assistant Professor, Department of Otolaryngology and Head and Neck Surgery The Ohio State University Columbus, USA Sumeet Pahwa Fellow, Surgical Oncology Prince Aly Khan Hospital Mumbai, Maharashtra India Prathamesh S Pai Associate Professor Department of Head and Neck Surgical Oncology Tata Memorial Center Mumbai, Maharashtra India

Giampiero Parrinello MD Otolaryngologist, PhD Student SOD Otolaryngology Department of Surgical Sciences AOU-Careggi, University of Florence Vle Morgagni Florence, Italy Prashant Patil Associate Professor JN Medical College Belgaum, Karnataka India Amol Patil Department of Otorhinolaryngology and The Skull Base Group Dr Balabhai Nanavati Hospital Mumbai, Maharashtra India R N Patil Professor Department of ENT, KLE University’s JN Medical College and Consultant ENT surgeon, KLES Dr Prabhakar Kore Hospital Belgaum, Karnataka, India Sultan A Pradhan Professor and Chief Oncologist Department of Surgical Oncology Prince Aly Khan Hospital Mumbai, Maharashtra, India Rashmi Prashant Assistant Professor, Department of ENT DY Patil Medical College Pimpri, Maharashtra, India Alberto Prats-Galino MD PhD Laboratory of Surgical Neuroanatomy (LSNA) Faculty of Medicine Universitat de Barcelona Barcelona, Spain

xvi Otology and Lateral Skullbase Surgery Daniel M Prevedello Assistant Professor Department of Neurological Surgery The Ohio State University Columbus, USA

Marc Remacle Otolaryngology Head and Neck Surgery Department Louvain University Hospital of ­Mont-Godinne, Yvoir, Belgium

Ashutosh G Pusalkar Emeritus Professor, Padmashree Dr DY Patil Medical College, Honorary Consultant Lilavati Hospital and Medical Research Center Mumbai, Maharashtra, India

Roberta Rehder MD Resident Program Evangelic Universitary Hospital Curitiba Paraná – Brazil

Ullas Raghavan FRCS (ORL-HNS) Doncaster Royal Infirmary Hospital Doncaster, UK S Raghunandhan MS DNB

MRCS (Ed) DOHNS

Consultant ENT Surgeon Department of Implant Otology Madras ENT Research Foundation Raja Annamalaipuram Chennai, Tamil Nadu, India Kannan Rajan Senior Oncosurgeon Department of Surgical Oncology Prince Aly Khan Hospital Mumbai, Maharashtra, India Reema Rai Resident Department of ENT and Head and Neck Surgery TN Medical College and BYL Nair Charitable Hospital Mumbai Maharashtra, India Suthee Rattanathummawat MD ENT Phramongkutklao Hospital Medical University Bangkok, Thailand C Rayappa Department of Head and Neck and Skull Base Surgery Apollo Speciality Hospital Chennai, Tamil Nadu, India

Gresham T Richter MD Department of Otolaryngology— Head and Neck Surgery University of Arkansas for Medical Sciences Arkansas Children’s Hospital Little Rock, Arkansas, USA

H Sadick Head and Chair of the Department of ORL and Head and Neck Surgery University Hospital of Mannheim Mannheim Germany Dariusz Sagan Department of Thoracic Surgery Medical University of Lublin Poland Lucel E Salvan DA Secretary ENT-Voice Center Yanhee International Hospital Bangkok Thailand

Nestor Rigual Department of Head and Neck/ Plastic Surgery, Roswell Park Cancer Institute, Buffalo, NY, USA

Suresh Sankhla

Supriya Rode Resident – Department of ENT and Head and Neck Surgery TN Medical College and BYL Nair Charitable Hospital Mumbai, Maharashtra, India

Zoukaa Sargi

Philippe Rombaux Department of Otorhinolaryngology University of Louvain Cliniques Saint Luc Brussels Av Hippocrate, Brussels, Belgium Sabino Russo MD Consultant in Otolaryngology Head and Neck Surgery Department of Otolaryngology Head and Neck Surgery National Cancer Institute Giovanni Paolo II Vle Flacco Bari, Italy

Department of Neurosurgery Dr Balabhai Nanavati Hospital Mumbai, Maharashtra India

Department of Otolaryngology, Head and Neck Surgery, University of Miami Miller School of Medicine Miami Florida, USA Tamer Seyhan MD Assoc. Prof. of Plastic Reconstructive and Esthetic Surgery Adana Numune Education and Teaching Hospital Cukurova, Adana Turkey Nishit J Shah Department of ENT Bombay Hospital Mumbai, Maharashtra India

Contributors xvii Jatin P Shah

MD MS (Surg) FACS Hon FRCS

(Edin) Hon FDSRCS (London) Hon FRACS

Professor of Surgery EW Strong Chair in Head and Neck Oncology Chief Head and Neck Service Memorial Sloan Kettering Cancer Center New York, USA Hemant Sharma Resident Department of ENT and Head and Neck Surgery TN Medical College and BYL Nair Charitable Hospital Mumbai, Maharashtra, India Atsushi Shiraishi Department of Ophthalmology Ehime University School of Medicine Shitsukawa, Toon, Ehime, Japan A M Shivakumar Professor and Head Department of ENT SS Institute of Medical Sciences and Research Center, Davangere, India

Murat Songu Department of Otorhinolaryngology —Head and Neck Surgery Dr Behçet Uz Children’s Hospital, Izmir, Department of Otorhinolaryngology Head and Neck Surgery, Izmir Ataturk Research and Training Hospital Izmir, Turkey Jonathan E Sorrel Department of Otolaryngology Head and Neck Surgery Louisiana State University Health Sciences Center and School of Medicine New Orleans, Louisiana, USA Giuseppe Spinelli MD Maxillo-Facial Surgeon Chief of the Department of Traumatology and Maxillo-Facial Surgery AOUC Hospital and University of Florence Largo Palagi Florence, Italy Ornouma Sriwanishvipat MD ENT Yanhee International Hospital Bangkok, Thailand

Shy Stahl MD Attending Surgeon, Division of Plastic and Reconstructive Surgery Sheba Medical Center, Tel-Aviv University, Ramat Gan, Israel

Milan Stankovic MD Clinic for ORL Medical Faculty University of NIS Serbia

Michael C Singer MD Instructor Department of Otolaryngology— Head and Neck Surgery Medical College of Georgia, Georgia

Andrzej Stepulak Department of Biochemistry and Molecular Biology Medical University of Lublin Poland

PP Singh Director-Professor and Head Department of ENT and Head Neck Surgery, University College of Medical Sciences and GTB Hospital New Delhi, India

RJ Stokroos Department of Otorhinolaryngology and Head and Neck Surgery Maastricht University Medical Center The Netherlands

Girish Surlikar MS (opthal)

DOMS FCPS DNB

Ophthalmologist Private Practice Mumbai, Maharashtra India Harumi Suzaki Department of Otorhinolaryngology Showa University School of Medicine Hatanodai, Shinagawa Tokyo, Japan Andrew C Swift Consultant ENT Surgeon and Rhinologist Aintree University Hospitals Foundation NHS Trust Liverpool, UK Taizo Takeda MD Emeritus Professor Kochi Medical School Kochi, Japan Paul A Tennant MD Resident in Otolaryngology University of Louisville Kentucky, USA David J Terris MD FACS Porubsky Professor and Chairman Department of Otolaryngology— Head and Neck Surgery Medical College of Georgia, Georgia Alok Thakar Department of Otorhinolaryngology All India Institute of Medical Sciences (AIIMS) New Delhi, India Kiskumar Thankappan Amrita Institute of Medical Sciences Elamakkara Kochi, Kerala, India

xviii Otology and Lateral Skullbase Surgery C Thomas MS FRCS FACS Senior Consultant and Head Plastic Surgery Service in Oman

Gauri Vaidya Department of ENT Bombay Hospital Mumbai, Maharashtra, India

Livnat Siman Tov MD Aesthetic and Reconstructive Plastic Surgeon, Jerusalem, Israel

Saurabh Varshney Professor and Head Department of ENT Himalayan Institute of Medical Sciences, (HIHT University) Jolly Grant; Doiwala Dehradun, Uttarakhand, India

Jagadish Tubachi Fellow Department of Surgical Oncology Prince Aly Khan Hospital Mumbai, Maharashtra, India Jumroon Tungkeeratichai Assistant Professor Facial Plastic and Reconstructive Surgery Otolaryngology Head and Neck Surgery, Faculty of medicine Ramathibodi Hospital Mahidol University Bangkok, Thailand Prof Tuncay Ulug MD Department of Otorhinolaryngology Istanbul University-Istanbul Medical Faculty Capa, Istanbul, Turkey Hirohito Umeno MD Associate professor Otolaryngology Head and Neck Surgery Kurume University School of Medicine Asahi-Machi Kurume, Japan Abhishek D Vaidya Fellow, Head and Neck Surgery Tata Memorial Hospital Mumbai, Maharashtra, India

B K Venkatesha Department of ENT SS Institute of Medical Sciences and Research Center Davangere, Karnataka, India Giovanni André Pires Viana MD Cliniplast Al. Jauaperi São Paulo, SP, Brazil Rohan R Walvekar MD Associate Professor Department of Otolaryngology Head and Neck Surgery Louisiana State University Health Sciences Center Bolivar Street New Orleans, Louisiana, USA

Parag Watve Resident Department of ENT and Head and Neck Surgery TN Medical College and BYL Nair Charitable Hospital Mumbai Maharashtra India Stephen Wetmore MD Professor and Chair Department of Otolaryngology West Virginia University School of Medicine Morgantown, West Virginia, USA Jeremy B White Plastic Surgeon ARC Plastic Surgery Stirling Road Hollywood, Florida, USA Adele P Williams Department of Otolaryngology Head and Neck Surgery Louisiana State University Health Sciences Center Bolivar Street New Orleans, Louisiana, USA

Jeremy Warner MD Division of Plastic Surgery North Shore University Health System, Central Street Evanston, Illinois, USA

Eyal Winkler MD Assistant Professor of Plastic Surgery Director of the Division of Plastic and Reconstructive Surgery Sheba Medical Center Tel-Aviv University Ramat Gan Israel

JJ Waterval Department of Otorhinolaryngology and Head and Neck Surgery Maastricht University Medical Center The Netherlands

R Yadav MS (ENT) DORL FCPS Assosiate Professor Rajawadi Hospital Mumbai, Maharashtra India

Contributors xix Kazunari Yoshida Associate Professor Department of Neurosurgery Keio University School of Medicine, Japan

Alper Yüksel Fatih University, Faculty of Medicine Department of Otorhinolaryngology Head and Neck Surgery Ankara, Turkey

Diego Zanetti Department of Otorhinolaryngology San Gerardo Hospital University of Milano Bicocca Monza, Italy

Ramzi Younis Department of Otolaryngology University of Miami School of Medicine, USA

Olaf Zagólski MD PhD ENT St John Grande’s Hospital Kraków, Poland

Maria Zisiopoulou Department of Otorhinolaryngology The University of Mainz Hospitals and Clinics, Mainz, Germany

Contents xxi

Foreword In spite of significant advances made in the multidisciplinary treatment of diseases and neoplasia in the head and neck region, surgery remains the mainstay amongst all therapeutic modalities currently available for these conditions. Surgical techniques have however, undergone significant evolution with major emphasis on preservation or restoration of form and function. This has resulted in the development of minimally invasive techniques. Technological advances in endoscopic instrumentation have ushered in the era of endoscopic surgery, replacing the well-established techniques of open surgery of the nasal cavity and paranasal sinuses. Major strides in imaging techniques over the past three decades, has facilitated accurate assessment of the extent of a neoplasm and has facilitated development of computer-assisted surgical techniques with intraoperative navigation and Robotic surgery. Thus, the surgical specialty of Otolaryngology and Head & Neck Surgery has dramatically changed over the years, and remains a challenging and continuously evolving field. The editors of this magnificent work, Drs Bachi T Hathiram and Vicky S Khattar have done a splendid job in putting together a state-of-the art surgical atlas by recruiting specialists from all parts of the world who have contributed their specific areas of expertise in demonstrating surgical techniques. The atlas is lavishly illustrated with operative pictures, imaging studies, and superb artwork to accompany the procedural details and operative photographs. The rationale, indications, step-by-step details of the procedure, and postoperative management and complications, makes this a complete surgical treatise, equally useful to the trainee and the surgeon in practice. This opus of operative surgery is presented in five volumes, covering a total of 195 operative procedures and their variations. The compilation covers nearly all the operative procedures from the ‘Dura to Pleura’, in the repertoire of the Otolaryngologist /Head and Neck Surgeon. This would be an essential textbook for a surgeon or surgeon in training, to familiarize oneself with an operative procedure, and go prepared to the operating room to carry out a safe and successful surgical procedure. The Editors and the Publishers of this excellent Atlas are to be commended for bringing about this excellent book, and offering it at an affordable price to surgeons of all generations. I am confident that this book will be an essential ‘read’, for Otolaryngologist / Head and Neck Surgeons, worldwide for years to come. Jatin P Shah MD MS (Surg) FACS Hon FRCS (Edin) Hon FDSRCS (London) Hon FRACS

Professor of Surgery Elliot W Strong Chair in Head and Neck Oncology Memorial Sloan Kettering Cancer Center New York, USA

Contents xxiii

Foreword It is a pleasure to write the foreword for the Atlas of Operative Otorhinolaryngology and Head & Neck Surgery. Today, the field of Medicine and especially the field of Otorhinolaryngology and Head & Neck Surgery is advancing by leaps and bounds in expertise and technology. With evidence-based medicine being at the forefront of our practice, mastering the skills of the surgical technique and the rationale behind this is of equal importance to the surgeon. There are various centers of excellence all over the world specializing in particular aspects of our field and it is common practice for the trainee doctors as well as established surgeons to visit these from time to time to learn and to upgrade their skills. This exhaustive compilation by the editors, Dr Bachi T Hathiram and Dr Vicky S Khattar is an attempt to bring together the best in the field of Otorhinolaryngology and Head & Neck Surgery under one title. With its five volumes on Otology and Lateral Skullbase Surgery, Rhinology and Anterior Skullbase Surgery, Facial Plastics, Cosmetics and Reconstructive Surgery, Voice and Laryngotracheal Surgery and Head & Neck Surgery, the editors have aimed to cover topics dealing with routine procedures as also, those that are at the cutting edge of technology. The Atlas comprises of 195 Chapters with intraoperative images and clear line diagrams/figures making it easy to understand the surgical steps. There are contributors from all over the world, each a master in his/her own technique. More than 30 countries have participated in this mammoth and prestigious venture thus, making it unique in our field and one of a kind, lending to it a truly global perspective. In addition to this pictoral step-by-step depiction of surgeries, there will follow a similarly exhaustive compilation of teaching DVDs which will further enhance the learning process. I am sure this academic venture will go a long way in benefitting not only the trainees but also established specialists. Milind V Kirtane Professor Emeritus Seth GS Medical College Hon Surgeon at KEM Hospital Hon Consulting ENT Surgeon at PD Hinduja National Hospital Hon ENT Consultant to his Excellency the Governor of Maharashtra Hon ENT Consultant at Prince Aly Khan Hospital Mumbai, Maharashtra, India

Preface In today’s age of rapid advances in science and technology, there is no dearth of learning material available to the avid learner. However, in the field of Otorhinolaryngology and Head & Neck Surgery, there seemed a lacuna between undergoing surgical training at various places and understanding the concepts/rationale behind the surgical technique. This book is a modest attempt by the editors to bridge this lacuna by going through each surgery in a simple step-wise manner using intraoperative images and illustrated figures, wherever required, to help understand the technique of surgery. This is essentially an atlas and hence, the stress on learning through intraoperative images and illustrations, making it easy for the trainee as well as the ENT consultant to follow the surgery. The authors are masters in the field and this is a mammoth compilation from more than 30 countries from all over the world since knowledge cannot be bound by any barriers. We feel that it is never too late to learn and especially as surgeons, it is imperative to keep in touch with the recent advances in our field and we hope to spread this message amongst our fraternity through this atlas. The Atlas discusses not only routinely performed surgeries, such as tonsillectomy, septoplasty, tympanoplasty, thyroidectomy and tracheostomy but also the latest advances in our field such as robotics, endoscopic skullbase surgery and sialoendoscopy. It is targeted to young trainee surgeons as well as specialists in the field who would like to learn the techniques of surgery from the masters. Bachi T Hathiram Vicky S Khattar

Acknowledgments We would like to express our gratitude to our publishers, M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India, especially Shri Jitendar P Vij for having the vision and faith in us, Ms Chetna Malhotra Vohra for her patience, perseverance and perfection, Ms Payal Bharti, Mr Arun Sharma and the entire team for their untiring efforts in completing this book on time. Also, we would like to thank all our students who have taught us in addition to learning from us; Reema Rai, Harshad Nikte, Parag Watve, Harshal Sonavane, Snigdha Devane, Anjoo Choudhary, Alok Nema, Supriya Rode, Balagopal Kurup, Hemant Sharma, Sunil Khot, Sanket Dani, Ankit Jain, Diptarka Bhattacharya, Sobhana Chandran and Lubna Sayed. They have all contributed to the making of this Atlas in significant ways. Most importantly, our teachers who have not only taught us surgery but, given us the drive to teach and impart knowledge.

Contents xxix

Contents

Vol. 1: Otology and Lateral Skullbase Surgery 1–366 (Chapters 1 to 44) Vol. 2: Rhinology and Anterior Skullbase Surgery 367–794 (Chapters 45 to 88) Vol. 3: Facial Plastics, Cosmetics and Reconstructive Surgery 795–1106 (Chapters 89 to 111) Vol. 4: Voice and Laryngotracheal Surgery 1107–1324 (Chapters 112 to 148) Vol. 5: Head and Neck Surgery 1325–1654 (Chapters 149 to 195)

Volume 1 1. The Surgical Technique of Otoplasty Murat Songu (Turkey)

3



2. Single Stage Pinna Reconstruction Jumroon Tungkeeratichai (Thailand)

22



3. Treatment of Earlobe Keloids Stahl Shy, Haik Josef, Goldan Oren, Eyal Winkler (Israel)

35



4. Preauricular Sinus Vicky S Khattar, Bachi T Hathiram, Snigdha Devane, Supriya Rode (India)

39



5. External Auditory Canal Obliteration Vicky S Khattar, Bachi T Hathiram (India)

42

6. Meatoplasty Vicky S Khattar, Bachi T Hathiram (India)

49



7. Intratympanic Injection Vicky S Khattar, Bachi T Hathiram, Supriya Rode, Hemant Sharma (India)

58



8. Surgical Approaches to the Middle Ear Cleft and Their Indications Vicky S Khattar, Bachi T Hathiram (India)

62



9. Tympanoplasty (Author’s Technique) Shabbir Indorewala (India)

67

10. Ossiculoplasty Amith I Naragund, RS Mudhol (India)

75

xxx Otology and Lateral Skullbase Surgery 11. The Vibrant Soundbridge Ashutosh G Pusalkar (India)

81

12. Totally Implantable Middle Ear Device Esteem Maurizio Barbara, Claudio Macrì, Simonetta Monini (Italy)

89

13. The Surgical Management of Cholesteatoma T Nikolopoulos, P Gerbesiotis (Greece)

92

14. Transposed Canal Wall Tympanomastoidectomy Tuncay Ulug (Turkey)

106

15. Inside-Out Mastoidectomy Amol Patil, Sonal Modi, Madhuri Mehta, Narayan Jayashankar, KP Morwani (India)

112

16. The Surgical Management of Congenital Cholesteatoma Jennings R Boyette, Gresham T Richter (USA)

124

17. The Technique of Otoendoscopy for Cholesteatoma Surgery Mohamed Badr-El-Dine (Egypt)

132

18. Endoscopic Management of Cholesteatoma RN Patil (India)

148

19. Surgical Management of Complications of Chronic Suppurative Otitis Media Bachi T Hathiram, Vicky S Khattar (India)

161

20. Tympanosclerosis: Surgery and Hearing Results Milan Stankovic (Serbia)

168

21. Stapedotomy Vicky S Khattar, Bachi T Hathiram (India)

177

22. Total Decompression of the Facial Nerve—Superior Prelabyrinthine Cell Tracts Approach Taizo Takeda, Akinobu Kakigi (Japan)

190

23. Zygomatic Root Approach Tuncay Ulug (Turkey)

194

24. Decompression of the Facial Nerve Following Traumatic Palsy Bachi T Hathiram, Vicky S Khattar (India)

200

25. Bone Conduction Implants Gauri Mankekar (India)

212

26. Minimally Invasive Cochlear Implantation with Mastoidal Three-Layer Flap Tuncay Ulug (Turkey)

224

27. Cochlear Implants Milind Kirtane (India)

231

28. Cochlear Implantation Arun K Gadre, Lynzee N Alworth, Katie L Austin, Paul A Tennant (USA)

235

29. Cochlear Implants M Kameswaran, S Raghunandhan (India)

251

Contents xxxi 30. Totally Implantable Hearing Devices M Kameswaran, S Raghunandhan (India)

261

31. Auditory Brainstem Implants M Kameswaran, S Raghunandhan (India)

265

32. Direct Acoustical Cochlear Stimulator M Kameswaran, S Raghunandhan (India)

270

33. Electro-Acoustic Stimulation/Hybrid Implants M Kameswaran, S Raghunandhan (India)

272

34. Auditory Midbrain Implants M Kameswaran, S Raghunandhan (India)

274

35. Endolymphatic Sac Surgery for Meniere’s Disease Stephen Wetmore (USA)

278

36. Transmastoid Repair of Temporal Meningoencephaloceles and Cerebrospinal Fluid Otorrhea Diego Zanetti, Werner Garavello, Lorenzo Gaini (Italy)

283

37. The Surgical Management of Cerebrospinal Fluid Otorrhea Bachi T Hathiram, Vicky S Khattar (India)

296

38. Decision-Making in Lateral Skull Base Surgery KP Morwani, Narayan Jayashankar, Suresh Sankhla, Rahul Agrawal (India)

303

39. Middle Fossa Approach JJ Waterval, RJ Stokroos, J Dings (Netherlands)

311

40. Surgical Approach to Jugular Foramen Tumors (Infratemporal Fossa Type A) C Rayappa (India)

317

41. Enlarged Translabyrinthine Approach KP Morwani, Narayan Jayashankar, Suresh Sankhla, Lalita Naik (India)

324

42. Management of Vestibular Schwannoma: Dependence on Stakeholder’s View for Small and Medium-Sized Tumors Haralampos Gouveris, Maria Zisiopoulou, Wolf J Mann (Germany)

334

43. Gamma Knife Radiosurgery for Vestibular Schwannomas Roman Liscak (Czech Republic)

341

44. Jugular Glomus: Literature Review and Surgical Technique Cassio Zottis Grapiglia, Roberta Rehder, Ali Diaz Castillejos, Luis A B Borba (Brazil)

350

Index I-i-vii

The Surgical Technique of Otoplasty 3 CHAPTER

1

The Surgical Technique of Otoplasty Murat Songu

The prominent ear is the most common congenital deformity of the auricle, occurring in approximately 5% of the Caucasian population and is inherited as an autosomal dominant trait (Figs 1A and B).1 Although the physiological consequences are insignificant, the psychological and aesthetic consequences on the patient can be considerable. The most common defects that prompt surgical consultation are a poorly developed or absent antihelical fold, an abnormally large concha and a prominent lobule.1 Otoplasty is a century-old procedure that has undergone many modifications over the years. Over 200 different procedures have been described in the literature that excise, bend, suture, scratch, or reposition the auricular cartilage. This plenty of surgical techniques show that no simple “best” technique exists.

A

INDICATIONS FOR THE SURGERY

Appropriate surgical planning relies on a thorough understanding of the normal and prominent ear. The major visible and palpable landmarks of the ear are composed of five critical elements, concha, helix, antihelix, tragus and lobule, and parts of lesser importance, including the antitragus, intertragic notch and Darwin’s tubercle (Fig. 2).2 The anatomical divisions of the ear are based in embryology, with its origins based from the first mandibular and second hyoid branchial arches. The hyoid arch is the predominant contributor leading to the formation of the helix, scapha, antihelix, concha, antitragus and lobule, whereas the mandibular arch only contributes to the tragus and helical crus. The ultimate shape is essentially determined by 20 weeks gestation and 85% of growth occurs by age of 3 years.3

B Figs 1A and B: (A) Preoperative; (B) Postoperative photographs of two brothers with protruding ears

4 Otology and Lateral Skull Base

Fig. 2: The major landmarks of the external ear

Kalcioglu et al. compared the growth ratios of the auricle in 1,552 volunteers from birth until age of 18 years.4 The development of the auricle regarding the transverse growth and the growth of the conchal depth was fully completed by the age of six years, independent of gender. Only the growth in auricular length continued until the age of 11 years. Even so, the length of the auricle increases during the natural aging process because of the natural skin and soft tissue elasticity. Ito et al. evaluated 1958 volunteers aged 5 to 85 years regarding their growth in auricular length and revealed that the increased replacement of elastic auricular cartilage fibers by collagen-like fibers is responsible for the growth in auricular length at an advanced age.5 Despite these results, otoplasty in pediatric patients has no significant influence on later auricular growth.6 The vascular supply to the auricle is provided by branches from the external carotid artery. The superficial temporal artery supplies much of the anterior portion, including the lobule, whereas the posterior supply is derived from the posterior auricular artery. The venous drainage replicates the arterial supply in reverse. The parotid lymph nodes and posterior auricular nodes with further contribution from level 2 and level 5 cervical beds serve lymphatic drainage. The innervation to the external ear consists of the anterior and posterior branches of the great auricular nerve, which innervates the first branchial arch structures tragus and helical crus, and the auriculotemporal nerve, which innervates the second branchial arch structures helix, scapha, antihelix, concha, antitragus, external acoustic meatus and lobule. The external auditory meatus also receives innervation from branches of the vagus and glossopharyngeal nerves.

Fig. 3: Prominent ears showing increased helix-mastoid angle, antihelical hypoplasia, cavum hyperplasia and protruding lobule

The most common indication for performing otoplasty is the prominent ear (Fig. 3). Other indications for otoplasty include trauma, cupped ear deformity or to correct a previous poor result. Anatomic norms for human ears have been established, thus it is possible to more objectively quantify patients who have irregular, prominent ears. Janis and Rohrich summarized the proportions that are common in the normal, esthetic ear Table 1.7-13 While the measurements and proportions of a “normal” ear have been well documented, the position of anatomical landmarks, and relation to one another at the end of the otoplasty procedure, are far more important. The ears must look proportional to the facial features and have a natural appearance. Prominent ear occurs as a result of one or more anatomic variants. Most often there is a lack of an adequate antihelix; the ear is less furled back on itself and thus protrudes from the skull. Another common anatomic finding in patients with prominent ears is a relative excess of conchal bowl cartilage. A third component can be an ear lobule that is excessive in size or positioned laterally. The basic goals of otoplasty were summarized by McDowell in 1968 and are listed in Table 2.7 LaTrenta suggested that three common anatomical goals always must always be kept in mind: production of a smooth, rounded and well-defined antihelical fold; a conchoscaphal angle of 90; and conchal reduction or reduction of the conchomastoidal angle.14

The Surgical Technique of Otoplasty 5 Table 1: Proportions of the esthetic ear

Table 2: McDowell’s basic goals of otoplasty

The long axis of the ear inclines posteriorly at approximately a 20° angle from the vertical. The ear axis does not normally parallel the bridge of the nose the angle differential is approximately 15°. The ear is positioned at approximately one ear length 5.5–7 cm posterior to the lateral orbital rim between horizontal planes that intersect the eyebrow and columella. The width is approximately 50–60% of the length width, 3–4.5 cm, length, 5.5–7 cm. The anterolateral aspect of the helix protrudes at a 21 to 30º angle from the scalp. The anterolateral aspect of the helix measures approximately 1.5 to 2 cm from the scalp although there is a large amount of racial and gender variation. The lobule and antihelical fold lie in a parallel plane at an acute angle to the mastoid process. The helix should project 2 to 5 mm more laterally than the antihelix on frontal view.

All upper third ear protrusion must be corrected. The helix of both ears should be seen beyond the antihelix from the front view. The helix should have a smooth and regular line throughout. The postauricular sulcus should not be markedly decreased or distorted. The helix to mastoid distance should fall in the normal range of 10 mm to 12 mm in the upper third, 16 mm to 18 mm in the middle third, and 20 mm to 22 mm in the lower third. The position of the lateral ear border to the head should match within 3 mm at any point between the two ears.

SPECIFIC PREOPERATIVE EVALUATION

Low self-esteem, general lack of self confidence and social isolation are amongst the reasons why parents of affected children or affected adults decide for otoplasty. In a study by Sheerin et al. children with prominent ears were evaluated by a psychiatrist before undergoing surgical correction.15 An increased tendency towards depression, lower achievements in school, lower self-esteem, and sociocommunicative problems in school and at home were observed. Schwentner et al. interviewed patients before and after otoplasty regarding their pre- and postoperative emotional state, using a standardized questionnaire.16 The results showed an improved attitude towards life, increased courage to face life, and better self-confidence among the patients, with no difference between male and female subjects. Horlock et al. stated that 74% of adults and 91% of children reported an improvement in selfconfidence resulting in improved quality of life.17 The appropriate time for the correction of prominent ears should depend on a rational approach based on auricular growth and age of school matriculation. Although the concern for ridicule and its effect on social development has been clearly illustrated, many children are not referred for otoplasty until teasing becomes an issue.17,18 Otoplasty procedure in children is recommended to be performed prior to the start of schooling.19 The hope is to correct the malformation before the time of socialization in order to minimize ridicule by peers. However, substantial

psychological pressure exposed to children with protruding ears among the peers at the preschool period or in kindergarten is usually underestimated. Changing socioeconomic trends have increased the proportion of families in which both parents work outside of the home. As a result, children have been increasingly exposed to peers through day care centers well before age four or five years. This intense early exposure to peers and caretakers outside of the family may significantly affect development of self-esteem. We observed that these children can provide information about their psychological strain or possible problems with other children associated with their protruding ears. Furthermore, these children can also express concern about the abnormal appearance of their ears before age five.20 Like many procedures involving the child’s face, there is a concern about how the operative site will respond to pressures of normal growth. Until recently, very few surgeons felt comfortable operating on the ear of a young child due to concerns about longevity and altered growth. Adamson et al. studied the growth patterns of the external ear of 2,300 ears and showed that the ear reaches 85% of its adult size by 3 years of age.3 On the other hand, Farkas differed some in his measurements stating that the ears reach 85% of full size by age 6, 90% by age 9, and 95% by age 14.21 Balogh and Millesi were the only authors to objectively study growth alterations following otoplasty and concluded that growth of the ear is not arrested following otoplasty.6 Recently, Gosain and colleagues reported that otoplasty can be safely performed under age 4 and as young as 9 months without significant effect on ear growth in a cohort of 12 patients with prominent ears.22,23 Due to our experience, in unilateral “Jumbo” ears, we observed that the protruding ear is usually bigger than the unaffected ear in all dimensions. Growth alteration should be a desired consequence among these patients and this desire is another rationale for the early surgical intervention.

6 Otology and Lateral Skull Base Nevertheless, we did not observe any visible disturbance or growth restriction in our patients, even in the unilateral operated group (Figs 4A and B). An important advantage of performing otoplasty at these younger ages is the increased malleability of the auricular cartilage, decreasing the need to use cartilagecutting techniques. At this age, the auricular cartilage is characteristically pliable; however, elasticity decreases with advancing age, often demanding more aggressive treatment. The softer the auricular cartilage, the easier it is to shape the cartilage or auricle into the appropriate form and pin it back, using gentle surgical techniques. We have previously published the surgical technique we prefer for management of the prominent ears in children.24 The Négrevergne otoplasty technique was popularized in the Institut Georges Portmann in France. The technique includes partial-thickness posterior scoring of the auricular cartilage using monopolar cutting diathermy. Because the ear cartilage is weak under age five, cartilage scoring can be conservative, sufficient to release the cartilage spring only. The main disadvantage of the surgery before age five is postoperative difficulties dealing with the dressing. The procedure is best performed when the auricle has reached

A

maturation and the child is old enough to cooperate with the postoperative care. It must be kept in mind that correction before age five may complicate the postoperative course when the child, even if not intentionally pulls apart the bandage and potentially disrupts the repair. Our practice has shown that, all patients were followed by multiple extra visits for redressings, and as their fingers were constantly inside the bandage this resulted in more swelling and certainly greater risk of postoperative complications. Nevertheless, at the end of the follow-up period, no serious complications occurred and the patient showed full recovery in our series (Figs 5A and B).20 Following a detailed medical history, a meticulous evaluation of the anatomy is performed. Another aspect with significant impact on procedure planning is the analysis of the cartilage consistency and, in particular, the stiffness and thickness of the cartilage. The consistency of the cartilage is typically evaluated by palpitation and cautious, controlled bending. It is important in surgical planning to remember that the cartilage becomes more calcified and brittle with age. Different combinations of abnormalities on either ear are frequently observed. Furthermore, additional abnormalities, such as auricular appendages, Darwin tubercle etc., can also be excluded in many cases

B

Figs 4A and B: (A) Preoperative; (B) Postoperative photographs of the patient who underwent left unilateral otoplasty and adenoidectomy are shown to demonstrate the normal growth of the ear that had been operated on relative to the unaffected ear

The Surgical Technique of Otoplasty 7

A

B Figs 5A and B: (A) Preoperative; (B) Postoperative photographs of the patient who underwent bilateral otoplasty and adenoidectomy in combination with tonsillectomy. The ears remain relatively symmetric postoperatively

simply by an inspection-based diagnosis. Awareness of the potentially different contributions of deformities on either side is crucial, if symmetry is to be attained. Standard preoperative photographs and consent form for the procedure are taken. The purpose of the photographic documentation is to document the preoperative situation. A basic series should include full facial frontals and laterals of both ears. Frontal close-ups, obliques and posterior images of each ear are also helpful (Figs 6A to F). Taking postoperative photos at intervals of 6 and 12 months helps to monitor postoperative success and is also recommended for medicolegal reasons (Figs 7A and B).25,26 Prophylactic antibiotics are recommended for the majority of aesthetic and reconstructive procedures on the ear. The risk of chondritis is a sufficient indication to use an intraoperative dose of a broad spectrum antibiotic, and to prescribe a few postoperative days dosage of the similar agent. Just as important as the anatomic irregularities of the auricle are the expectations of the patient and family. It is important to discuss the potential outcomes and complications, and to ensure the patient has realistic expectations. The patients or the parents of the child are informed about the potential risks and unwanted complications, including hematoma and infections of skin or cartilage, and also regarding the possibility of an unsatisfactory

cosmetic result. The importance of diligent postoperative care to avoid complications must be also established before surgery. When counseling younger patients and their families, the ability of the younger otoplasty patient to appropriately participate in postoperative care and protection of the dressings should be addressed.

ANESTHETIC CONSIDERATIONS In an effort to reduce the potential surgical morbidity related to general anesthesia, current trends in aesthetic surgery have moved toward local anesthesia combined with sedation, as opposed to general anesthesia.27 Remifentanil has gained specific popularity due to its rapid effect and high patient tolerance for such indications.28 In children, general anesthesia has broadly been accepted a reasonable choice; however, at least one group is looking at the possibility of using local anesthesia with conscious sedation in children.29 Regardless of whether general anesthesia or monitored sedation is used, the use of local anesthesia results in decreased postoperative narcotic use and decreased pain scores.30 Local anesthesia can be delivered in a number of ways. A peripheral nerve block can provide broad range analgesia with one injection, as opposed to local infiltration, which must be precisely placed to have the appropriate effects. Local infiltration, however, has the

8 Otology and Lateral Skull Base

A

D

B

C

E

F

Figs 6A to F: Photographic documentation

A

B

Figs 7A and B: (A) Preoperative (B) Postoperative photographs of the patient who underwent bilateral otoplasty. The ears are symmetric postoperatively and rising self-confidence is apparent even in the photograph

The Surgical Technique of Otoplasty 9 added benefit of hemostasis when low-dose epinephrine is included. There are multiple choices of substances available as local anesthetics, including prilocaine, lidocaine, mepivacaine, bupivicaine and ropivaeaine. Koeppe et al. found that prilocaine and lidocaine were most commonly used while ropivaeaine had the lowest side-effect profile.31 Another study on ropivacaine found it to have comparable efficacy to bupivacaine specifically in otoplasty, but with a more desirable risk profile.32

SURGICAL STEPS In considering the proper surgical technique, there is a room for surgeon preference and vision. The surgeon should develop a complete surgical plan that is a conglomerate of the individual techniques necessary to correct each observed anatomic irregularity. Surgical techniques for the correction of the prominent ear can be grouped into maneuvers used to create the antihelical fold, to correct the conchal defect and to affect lobule positioning.

1. Perioperative Routine

keeps the hair out of the surgical field. Drapes are placed so that both ears are simultaneously on view providing intraoperative comparison to obtain optimal symmetry (Fig. 9).

2. Skin Incision As symmetry is the key, it is recommended to begin with the more severely affected side. Before local infiltration and associated tissue distortion, the area of redundant postauricular skin to be excised is estimated by gentle manipulation of the ear and traction in the desired position. The postauricular skin excision is then marked based on the estimation. Although most investigators have advocated an excision of skin, some have described a simple incision.25,33 The desired ear contours are simulated by exerting gentle digital pressure on the helix and newly formed antihelical fold is marked on the skin (Fig. 10). The posterior auricular skin and mastoid soft tissues are infiltrated subcutaneously with 1% Lidocaine HCl and 1:100,000 epinephrine solution. Local anesthesia enhances hemostasis and demarcates the plain of dissection.

There are as many variations in perioperative routine as there are in surgical technique for otoplasty. The hair is covered with a standard head bandage along the hairline. A small sterile cotton ball is placed in the external auditory canal to prevent blood from accumulating on the tympanic membrane (Fig. 8). The cleansing of the external ear is performed with povidone-iodine solution. Surgical draping with Tegaderm 3M Health Care, St Paul, MN or other clear sticky drape

Fig. 8: Small sterile cotton ball placed in the external auditory canal

Fig. 9: Surgical draping with clear sticky drape

10 Otology and Lateral Skull Base

Fig. 10: Ear contours are simulated by exerting gentle digital pressure on the helix. Newly formed antihelical fold and planned mattress sutures are marked on the skin

The estimated skin excision on the posterior surface of the ear can be done safely with the narrowest width at the middle third to avoid ‘‘telephone ear’’ deformity. This occurs when the middle portion is reduced to a relatively greater degree than the superior helix and lobule. This overcorrection in the middle breaks the straight line of the caudal helix and leaves a relatively over-projected superior helix and lobule, giving the ear a convexity similar to the shape of a traditional telephone (Fig. 11). The reverse phenomenon can also occur, if relatively less mid-portion correction is performed. This is termed a reverse telephone deformity. If a lobule prominence accompanies, the skin excision is finished with a diamond-shaped inferior end to correct the lower pole prominence. The maximal width of the diamond-shaped excision is designed to rest at the point of maximal lobule prominence (Fig. 12). Others describe creating a medial-based skin flap that is re-draped over the posterior auricle at the end of the case and excising the distal portion of the skin flap as needed to precisely fill the defect without tension or excess.17 The main advantage of this approach is tension-free closures, which may reduce the incidence of hypertrophic scars. The previously marked postauricular skin is widely undermined exposing the perichondrium. Hemostasis is meticulously maintained and dissection is developed peripherally to the free edge of the helix and posteriorly to the level of the mastoid bone. The bulky postauricular soft tissue, auricularis posterior muscle fibers and fibrofatty tissues cleanly excised off the perichondrium and mastoid fascia with preservation of the periosteum (Figs 13 and 14). Creation of a deep, mastoid pocket accommodates the repositioned conchal cup, facilitates posterior rotation of

Fig. 11: “Telephone ear’’ deformity evident on the sixth month control

Fig. 12: The estimated skin excision with a diamondshaped inferior end

the concha, removes the postauricular tissues that may act as a lever producing excessive prominence and enhances the setback by effectively reducing conchal height. Utilization of the mastoid pocket also serves to reduce distortion of the external auditory meatus.

3. Creation of the Antihelical Fold Many cases of prominent ears require reshaping of the antihelix. As mentioned earlier, a practical way to

The Surgical Technique of Otoplasty 11

Fig. 13: The subcutaneous tissue over the mastoid

Fig. 14: The bulky postauricular soft tissue, auricularis

surface of the cartilage is dissected

posterior muscle fibers and fibrofatty tissues excised

determine how much reshaping is needed is to bend the antihelix with digital pressure and then mark how the new anti-helix should look (Fig. 10). Cartilage incision techniques: The first aesthetic otoplasties described by Ely in 1881 and Luckett in 1910 were examples of cartilage incision techniques.34 These techniques include cartilaginous incisions or wedge excisions addressing either the antihelix or the cavum concha. 35-39 Luckett’s original procedure to create a new antihelical fold involved excising a crescentic segment of cartilage posteriorly and reapproximating the remaining edges to each other. When the edges of this cartilage bridge are folded back, it forms a tube, which is subsequently sutured to form a smooth, rounded, more natural-appearing antihelix. With any cartilage-cutting technique, there is the risk of creating visible contour irregularities and sharp edges, overcorrection and the appearance of an operated-on ear. Cartilage-sparing techniques: Cartilage-sparing techniques are emerged in an attempt to prevent potential contour irregularities that may develop with aggressive cartilage-cutting techniques. Mainly, suturing rather than cutting, is used to create the desired auricular contours, thereby preserving cartilaginous support and minimizing contour irregularities. In 1963, Mustarde first described the use of multiple horizontal mattress sutures placed in the posterior cartilage that incorporate the full thickness of the cartilage and anterior perichondrium but not the anterior skin to form the antihelical fold (Figs 15A and B).40 The sutures are then tightened to the extent required to appropriately reduce the defect and create an antihelix (Fig. 15C). To create the superior crus, the same type of stitch is secured onto the fossa triangularis. Mustarde has conducted two reviews of his own procedure. Of 264 ears operated over a 10-year period, 17 cases

were judged as unsatisfactory with problems, such as kinking within the antihelix, sutures cutting out and recurrence of prominence.41 A subsequent study of 600 ears operated over a 20-year period revealed a 0% incidence of stitch rejection, a 0.01% incidence of sinus tract formation and a 0.02% incidence of reoperation.42 Spira and Hardy studied their experience with the Mustarde technique and determined that there were a large number of relatively minor complications and a high rate of partial recurrence of the original deformity.43 Criticisms of the cartilage-sparing technique have focused on the relatively high rate of up to 25% loss of correction or the possibility of stitch extrusion up to 15%.43 Permanent sutures, more frequently initiate development of indolent infections or foreign-body granulomas. In these instances, removal of the offending suture is curative. Kaye and Tramier advocate an anterior approach to place the plication sutures in an effort to eliminating the need for extensive flap dissection and minimizing postoperative discomfort and risk of infection and hematoma.44,45 Horlock et al. proposed a method for eliminating problems with extrusion by raising a postauricular fascial flap.46 In this technique, rather than dissecting a single subperichondrial plane, a separate plane is dissected subdermally first and followed by the cartilage exposure to leave a mastoid-based fascial flap that can be repositioned over the sutures and provide a layer of protection to prevent extrusion. This maneuver did not significantly change the incidence of loss of correction when compared with other studies but did eliminate stitch extrusion. Adamson et al. retrospectively reviewed their experience with conchal setback and antihelical suture placement in 119 ears.47 They found that the superior pole became lateralized to approximately 40% of the original

12 Otology and Lateral Skull Base

B

A

Figs 15A to C: Mustarde suture. (A) Side and posterior

C

views of a constructed antihelix; (B) Dental needles marking the planned mattress sutures; (C) Precise tension placed on mattress sutures are shown in a patient operated for prominent ears accompanied by macrotia

correction, which led to revision in 6.5% of the ears. They recommended adding fossa triangularis–temporalis fascia sutures to correct this superior pole lateralization. Loss of superior pole correction was also reported by Messner and Crysdale in patients who underwent cartilage-sparing otoplasty, including placement of fossa triangularis– temporalis fascia sutures.48 The corrected ears returned to their preoperative position in one third of their cases and one third of their cases had a final position between their preoperative and postoperative positions. Despite this loss of correction, 85% of patients were satisfied with their results. Cartilage weakening techniques: Cartilage-weakening techniques are often used in an attempt to reduce the complications created by cartilage-cutting and

cartilage-sparing techniques. Although scoring of either the posterior or anterior auricular surfaces are injurious to cartilage, no full-thickness cartilaginous incisions are performed. Many different tools have been used, including scalpel, rasp, hypodermic needle, diamond burr drill and dermabrasion tool. Tan et al. advocated the widely available Adson-Brown forceps as their scoring instrument of choice while Di Mascio et al. reported a cartilage incising procedure that uses a dermabrader drill to score the anterior surface of the cartilage.49,50 Azuara reported his experience using a no. 15 blade in his technique, where the cartilage incisions allow a tension-free rolling of the cartilage posteriorly.51 Scoring techniques are mainly based on the observations that cartilage tends to warp away from an injured surface.52 Fry later confirmed this observation and

The Surgical Technique of Otoplasty 13 attributed it to “interlocked stresses” that were released by a perichondrial incision.53 Stenstrom and Chongchet applied this theory to otoplasty.54,55 Stenstrom’s initial technique consisted of anterior scaphal scoring to produce an antihelical fold.56 Qureshi observed the combination of the two cartilage-weakening methods and stated that scoring by scalpel blade on one side of the cartilage and bipolar diathermy on the other, produces greater warping towards the direction of the bipolared side.57 Heftner surveyed patient satisfaction with use of the Stenstrom technique and found that 89% were either very satisfied or just satisfied.58 He also noted that 14% of patients had a sharp contour. Calder reviewed 562 Stenstrom otoplasties and found a 16.6% overall complication rate with an 8% incidence of residual deformity.59 Many methods of posterior surface weakening were also described in the literature.24 These maneuvers include abrasion, scoring, partial-thickness incisions and longitudinal wedge excision.60-65 The deficiencies of these maneuvers are the need for special instrumentation and unreliability in producing consistent results. Nearly all of them are combined with a cartilage-sparing technique by using additional suture fixation. Combined techniques: Understanding the principles behind the various techniques may lead the surgeons to form surgical strategies based on personal surgical philosophies. Nolst Trenite used a scalpel to make multiple partialthickness cartilage incisions posteriorly, but stresses the importance of not incising the anterior surface perichondrium.66 In this approach, mattress sutures are added to set the final position. He reported two cases with noticeable sharp and two cases with ‘‘telephone-ear’’ deformities from poor suture placement in his series of 65 ears. Bulstrode et al. reported their experience using a precisely bent hypodermic needle to perform percutaneous cartilage scoring followed by posterior mattress suturing.67 Fritsch also described an approach that used a 21-gauge needle to score the cartilage anteriorly through a puncture site and Mustarde-type mattress sutures are placed percutaneously with the goal of the suture passing sub-perichondrially, with a common entrance and exit site.68 Yugueros et al. also reported a combined approach with anterior scoring through a small anterior incision, Mustardetype mattress sutures and conchal-mastoid sutures.69 One major difficulty in trying to objectively evaluate these techniques is the small number of literature of headto-head comparisons of the surgical philosophies. One European group compared a cartilage-cutting method of incising and folding the cartilage to reconstruct an antihelix with a modified mattress suture technique that included anterior scoring.70 Twenty eight patients were selected and compared by the length and breadth of the

ear; the superior, medial and inferior cephaloauricular distances and the conchoscaphal angle, as well as by using the Strasser evaluation system for appearance.71 They observed a statistically significant greater amount of asymmetry and decreased patient satisfaction when cartilage is incised. Panettiere et al. reported a study that compared a cartilage-incising technique versus a cartilage-weakening and mattress suture technique.72 Comparison was made by a blinded, independent surgeon’s review of follow-up photos. Ninety-two percent of the ears in the cartilageincising technique group had noticeably sharp edges, whereas none of the weakened and sutured ears displayed this irregularity in follow-up. Both methods were without recurrence in a 12-month follow-up. Tan et al. compared Mustardé’s posterior suturing technique with Stenstrom’s anterior scoring technique and found that although patient satisfaction with the aesthetic results were the same between the two approaches, ears treated by Mustarde’s method required more than twice as many reoperations.73 In a comparative study, Hyckel et al. compared Mustarde’s and Converse’s methods and found no objective or subjective differences.74

4. Correction of the Conchal Bowl Conchal deformity can be addressed by several methods, including scoring and suturing and excisional techniques and scoring. Conchal mastoid sutures can be used to correct conchal prominence of the ear. This suture technique was originally described by Owens and Delgado.75 Their method was subsequently modified by Furnas,76 who used nonabsorbable mattress sutures placed in the conchal cartilage and sutured it to the mastoid fascia (Fig. 16A). He stated that sutures placed too far forward on the mastoid or too far back on the concha will cause outward and forward rotation of the conchal cup, causing reduction of the external auditory canal diameter (Figs 16B and C). A popular excisional technique to control conchal bowl prominence involves separating the cartilage where the concha meets the tail of the helix and removing an adequate portion along the conchal rim. The cartilage must then be re-approximated. Proponents of this technique claim that this cartilage incision hides well in the natural convexity of the junction of the conchal bowl and antihelical fold. Excision techniques can also be used to reduce conchal hypertrophy. These techniques can be grouped into those that excise cartilage alone and those that excise both skin and cartilage. The cartilage-only procedures are usually performed through a posterior approach, whereas the skin and cartilage techniques are usually performed through an anterior approach. Finally, careful scoring may be used alone or in combination to reduce conchal prominence.

14 Otology and Lateral Skull Base

A

B

C

Figs 16A to C: Furnas suture. (A) Constructed conchal bowl on the axial plane. Permanent suture is used to medialize the conchal bowl (B) to the mastoid periosteum (C)

5. Lobule and Helical Rim Positioning The lobule can be an overlooked component of the prominent ear and appear accentuated after the auricle is repositioned. The lobule should rest in a straight line with the helical cartilage when viewed from the front. Beernink, in a study of 159 ears, stated antihelical correction corrected an associated protruding lobule in 28% of patients.63 Wood-Smith suggested a “fish tail-like” retrolobular skin excision with a subsequent V-Y plasty.77 Posterior lobule skin and fibrofatty tissue can be also excised in a V-shape, heart shape and eccentric elliptical patterns with suture approximation producing the desired setback. Additionally, a Z-plasty can be fashioned at the most inferior aspect of the postauricular incision, producing a similar effect. Gosain advocated a single stitch approach in which the loble is secured to the mastoid region.78 The excess skin is then excised and the incision is closed. Spira

et al. treat the protruding lobule by wedge-excision and a periosteum suture between the dermis and the scalp.79 Another method involves a curvilinear, fusiform excision from the anterior to posterior lobe margin with a central V excision to effect easy closure.1 One further consideration in the prominent ear, not mentioned elsewhere, is the helical curl itself. Often this can be flattened and floppy, further contributing to the overly abnormal appearance. Few investigators have focused on this particular aspect. One study does describe a simple wedge excision along the helix alone without extending into the scaphae.80 This shortens the outermost edge of the helix, enhancing its curl inward. This is used as an adjunct when the helix itself is noticeably flattened. In majority of our cases, we prefer a diamond-shaped posterior skin excision behind the lobule and suture the opposing points of the diamond in the closure using a

The Surgical Technique of Otoplasty 15 running, locked, 4-0 long-term absorbable suture. It obviates the discomfort of suture removal, especially in children (Fig. 12).

6. Dressing and Postoperative Care The appropriate dressing for the ear is a critical aspect of the procedure. At the completion of the procedure the wounds are carefully cleansed and dressed with greasy gauzes soaked in Bepanthen Plus 50 mg Dekspantenol, 5 mg klorheksidin HCI. It is extremely important that the greasy gauze be carefully molded to fit the new folds and contours of the ear and to gently pad the postauricular surface (Fig. 17). All patients are placed on a five-day regimen of antibiotics and acetaminophen as needed for pain. Aygit reported a custom-made mold for 2 weeks postoperative.81 Azuara used a moldable porous polyester splint in a similar fashion for 72 hours with a compression dressing fulltime for the first week postoperatively followed by 1 month of night time compression (Fig. 18).54 In our practice, the dressing is removed on the first postoperative day to inspect the ears. This facilitates early identification of complications, such as hematoma formation or skin ischemia. A slightly lighter dressing is replaced and is changed every other day for a further 7 days. After removal of the dressings, patients are instructed to wear a headband nightly for one month to prevent inadvertent nocturnal trauma. Patients are discouraged from any rough play or circumstances that might lead to accidental trauma, as a history of external trauma has been associated with about half of the cases of loss of correction requiring revision surgery.47 Patients are then typically seen at 3 to 6 months postoperatively and 1 year postoperatively to document results (Fig. 19).

NEW TECHNIQUES IN THE SURGERY The Négrevergne Otoplasty Technique The Négrevergne otoplasty technique adopted in the Institut Georges Portmann is a simple method of cartilage weakening mainly preferred in young children in our

Fig. 18: Headband to prevent inadvertent nocturnal trauma

Fig. 17: Molded greasy gauze placed to fit the new folds

Fig. 19: Seventeen-year-old boy before and

and contours of the reconstructed ear

six months after surgery

16 Otology and Lateral Skull Base practice.26 A surgical instrument, monopolar diathermy, which is already present in the surgical field, is used. Since the technique is suture-free, low-complication rates can be obtained. Common complications, such as suture failures and extrusions, suture material induced foreign-body granulomas and wound breakdown are never observed. In this technique, the cartilage under the desired fold is marked by inserting dental needles at two or three points from anterior-to-posterior fashion. The inserted needles mark the lines of cartilage weakening (Fig. 20). The monopolar diathermy in cutting mode is adjusted to a setting sufficient to create a partial-thickness trough through the cartilage. Three passes are made to form the antihelical fold while maintaining sufficient flexibility to prevent a sharp angle at the fold (‘A’ in Fig. 21 and ‘A’ in Fig. 22). Next, the conchal hypertrophy component is addressed. The conchal-mastoid groove has been cleared of the fibrofatty tissue and the postauricularis muscle previously as described. The ear is drawn backward into the desired position and the site of contact between the conchal cartilage and mastoid fascia is checked. The marked conchal limits are used to mark proposed conchal scoring incisions, which are parallel the long axis of the ear. Two or three incisions are made with a monopolar diathermy in cutting mode (‘B’ in Fig. 21 and ‘B’ in Fig. 22). This maneuver breaks the spring of the conchal bowl and leads the fibrosis to the mastoid fascia.

COMPLICATIONS Elliott divided unsatisfactory results of otoplasty into early complications and late sequelae.82 Early complications include hematoma, infection, chondritis, pain, bleeding,

pruritus and necrosis. Late sequelae include unsightly scarring, patient dissatisfaction, suture problems and dysesthesias. Early complications: Hematoma is one of the most dreaded immediate postoperative complications. It is heralded by the acute onset of severe, persistent and often unilateral pain. If encountered, the head dressing should be removed and sutures released to drain the hematoma. If there is evidence of ongoing bleeding, reoperation and exploration are mandatory. Infection is another potentially devastating complication of otoplasty, especially because it can lead to the development of chondritis and

Fig. 21: Axial view demonstrate the sequential effects of surgical maneuvers on ear protrusion. (A) Partial-thickness scoring of scapha to create antihelical fold; (B) Partial-thickness scoring of concha to break the spring of the cartilage

Fig. 20: Dental needles marking the lines

Fig. 22: (A) Frontal view shows partial-thickness scoring of

of cartilage weakening

scapha to create antihelical fold; (B) Partial-thickness scoring of concha to break the spring of the cartilage

The Surgical Technique of Otoplasty 17 residual deformity. Infection can be caused by a break in proper sterile surgical technique or dehiscence secondary to excessive tension during closure or it can be an untoward sequela of prior hematoma evacuation (Figs 23A and B). If redness, swelling and drainage are encountered, treatment with intravenous antibiotics is recommended, as is the use of topical mafenide acetate cream. The usual pathogens are Staphylococcus, Streptococcus and sometimes Pseudomonas. Chondritis is a surgical emergency. If left untreated, it can result in deformity. Therefore, prompt debridement of devitalized tissue is necessary. Late sequelae: Residual deformity is, by far, the most common unsatisfactory result of otoplasty. It usually is apparent by 6 months postoperatively and is manifested by one or more of the following: a sharply ridged antihelical fold; lack of normal curvature of the superior crus; irregular contouring; a malpositioned or poorly constructed antihelical fold; an excessively large scapha; and a narrow ear.83 Most of the time, the residual deformity is a result of poor surgical planning and execution rather than an inherent technical problem (Figs 24A to C). Persistent superior pole prominence was also noted by Georgiade et al.84 They recommended additional superior helix scoring or higher posterior vertical mattress suture placement to resolve this problem. Webster recommends slight overcorrection of the superior pole to allow for postoperative changes. The psychological and social outcomes

A

of prominent ear correction were evaluated by Bradbury et al. who found improved wellbeing in 90% of the children 12 months postoperatively.85

OTHER TREATMENT OPTIONS AVAILABLE FOR THE SAME CONDITION

Nonsurgical correction of prominent ears usually has poor results. There is evidence, however, that intervention within the first few days of life may adequately treat a prominent ear. Several investigators have applied splinting to prominent ears that were identified at birth with promising long-term results when applied within the first 3 days of life.86,87 However, delay of treatment yielded poor results. Tan attributes the loss of cartilage pliability after birth to decreasing levels for circulating maternal estrogens, which are highest in the first 3 days after birth and decrease to normal levels by 6 weeks of age.88,89 Matsuo et al. also reported no recurrence after 6 months when the prominent ear was corrected with surgical tape within 3 days of birth.90 However, results were poor when the taping was started after this period. Matsuo et al. also observed that the percentage of protruding ears increases from 0.4% at birth to 5.5% at 1 year of age and concluded that most protruding ears are acquired deformities. They

B Figs 23A and B: (A) Redness and swelling observed on the second postoperative day; (B) Regressed with antibiotics treatment

18 Otology and Lateral Skull Base

A

B

Figs 24A to C: (A) Tanzer type 2B cup ear deformity; (B)

C

postulated that the mechanism is that when a baby is placed in a supine position, the weight of the baby’s head will fold the ear forward when the baby turns its head to one side.91 This mechanism has not been definitively proven; thus, behavioral modification techniques have not been a mainstay of nonsurgical treatment. The Auri

Persistent superior pole prominence in the postoperative period; (C) The ears are symmetric 6 months after the revision surgery

method, popularized by Sorribes and Tos, uses a plastic clip device at night with a clear adhesive tape in the day to hold the auricle in a position that forces an antihelix. Treatment times were daily for 1 to 10 months. There is a substantial compliance related drop-out. Good correction is reported as high as 34% with an additional 55% with fair

The Surgical Technique of Otoplasty 19 correction.87 The combination of this splinting technique with the use of injectable cartilage molding compounds may have promising applications in a broader range of age groups and potentially shorter treatment times. Few basic science studies also focused on otoplasty procedure. Some recent research has been reported on cartilage reshaping in animal models. Preliminary studies using hyaluronidase and elastase injected into rabbit ears show statistically significant cartilage remodeling compared with saline alone when splinting is applied.92

SUMMARY Auricular deformities, specifically, prominent ears, are relatively frequent. Although the physiological consequences are negligible, the aesthetic and psychological effects on the patient can be substantial. Accurate preoperative diagnosis of the specific components of the deformity, proper planning and excellent technical execution of the procedure are paramount to obtaining a good, long-lasting and aesthetic result.

ACKNOWLEDGEMENT Medical photography consent forms are obtained from the patients or parents.

REFERENCES 1. Adamson PA, Strecker HD. Otoplasty techniques. Facial Plast Surg. 1995;11(4):284-300. 2. Tolleth H. Artistic anatomy, dimensions, and proportions of the external ear. Clin Plast Surg. 1978;5(3):337-45. 3. Adamson JE, Horton CE, Crawford HH. The growth pattern of the external ear. Plast Reconstr Surg. 1965;36(4):466-70. 4. Kalcioglu MT, Miman MC, Toplu Y, et al. Anthropometric growth study of normal human auricle. Int J Pediatr Otorhinolaryngol. 2003;67(11):1169-77. 5. Ito I, Imada M, Ikeda M, et al. A morphological study of age changes in adult human auricular cartilage with special emphasis on elastic fibers. Laryngoscope. 2001; 111(5):881-6. 6. Balogh B, Millesi H. Are growth alterations a consequence of surgery for prominent ears? Plast Reconstr Surg. 1992; 90(2):192-9. 7. McDowell AJ. Goals in otoplasty for protruding ears. Plast Reconstr Surg. 1968;41(1):17-27. 8. Skiles MS, Randall P. The anesthetics of ear placement: An experimental study. Plast Reconstr Surg. 1983;72(2):133-40. 9. Farkas LG. Anthropometry of normal and anomalous ears. Clin Plast Surg. 1978;5(3):401-12. 10. Farkas LG. Anthropometry of the normal and defective ear. Clin Plast Surg. 1990;17(2):213-21.

11. Tolleth H. A hierarchy of values in the design and construction of the ear. Clin Plast Surg. 1990;17(2):193-207. 12. Smith HW. Calibrated otoplasty. Laryngoscope. 1979; 89(4):657-65. 13. Janis JE, Rohrich RJ, Gutowski KA. Otoplasty. Plast Reconstr Surg. 2005;115(4):60e-72e. 14. LaTrenta GS. Otoplasty. In: Rees TD and LaTrenta GS (Eds). Aesthetic Plastic Surgery, 2nd edition. Philadelphia:Saunders; 1994;891-921. 15. Sheerin D, MacLeod M, Kusumakar V. Psychosocial adjustment in children with port-wine stains and prominent ears. J Am Acad Child Adolesc Psychiatry. 1995;34(12):1637-47. 16. Schwentner I, Schmutzhard J, Deibl M, et al. Health-related quality of life outcome of adult patients after otoplasty. J Craniofac Surg. 2006;17(4):629-35. 17. Horlock N, Vögelin E, Bradbury ET, et al. Psychosocial outcome of patients after ear reconstruction: a retrospective study of 62 patients. Ann Plast Surg. 2005;54(5):517-24. 18. Keery H, Boutelle K, van den Berg P, et al. The impact of appearance-related teasing by family members. J Adolesc Health. 2005;37(2):120-7. 19. Kelley P, Hollier L, Stal S. Otoplasty: evaluation, technique, and review. J Craniofac Surg. 2003;14(5):643-53. 20. Songu M, Adibelli H. Otoplasty in children younger than 5 years of age. Int J Pediatr Otorhinolaryngol. 2010; 74(3):292-6. 21. Farkas LG. Growth of normal and reconstructed auricles. In: Tanzer RC, Edgerton MT (Eds). Symposium on Reconstruction of the Auricle. St. Louis: Mosby; 1974;24-31. 22. Gosain AK, Recinos RF. Otoplasty in children less than four years of age: surgical technique. J Craniofac Surg. 2002; 13(4):505-9. 23. Gosain AK, Kumar A, Huang G. Prominent ears in children younger than 4 years of age: what is the appropriate timing for otoplasty? Plast Reconstr Surg. 2004;114(5):1042-54. 24. Songu M, Négrevergne M, Portmann D. The Négrevergne otoplasty technique. Ann Otol Rhinol Laryngol. 2010; 119(1):27-31. 25. Spira M. Otoplasty: what I do now--a 30-year perspective. Plast Reconstr Surg. 1999;104(3):834-41. 26. Becker W, Deutsch E, Knappen FJ, et al. [Panel discussion: problems of the specialist’s duty to inform the patient (author’s transl)] HNO. 1976;24(6):181-96. 27. Cregg N, Conway F, Casey W. Analgesia after otoplasty: regional nerve blockade vs local anaesthetic infiltration of the ear. Can J Anaesth. 1996;43(2):141-7. 28. Ferraro GA, Corcione A, Nicoletti G, et al. Blepharoplasty and otoplasty: comparative sedation with remifentanil, propofol and midazolam. Aesthetic Plast Surg. 2005;29(3):181-3. 29. Lancaster JL, Jones TM, Kay AR, et al. Paediatric daycase otoplasty: local versus general anaesthetic. Surgeon. 2003;1(2):96-8. 30. Pavlin DJ, Chen C, Penaloza DA, et al. Pain as a factor complicating recovery and discharge after ambulatory surgery table of contents. Anesth Analg. 2002; 953:627-34.

20 Otology and Lateral Skull Base 31. Koeppe T, Constantinescu MA, Schneider J, et al. Current trends in local anesthesia in cosmetic plastic surgery of the head and neck: results of a German national survey and observations on the use of ropivacaine. Plast Reconstr Surg. 2005;115(6):1723-30. 32. Romo T 3rd , Sclafani AP, Shapiro AL. Otoplasty using the postauricular skin flap technique. Arch Otolaryngol Head Neck Surg. 1994;120(10):1146-50. 33. Caouette-Laberge L, Guay N, Bortoluzzi P, et al. Otoplasty: anterior scoring technique and results in 500 cases review. Plast Reconstr Surg. 2000;105(2):504-15. 34. Ely ET. An operation for prominent auricles. Arch Otolaryngol. 1881; 10:97 (reprinted in Plast Reconstr Surg. 1968;42:582). 35. Becker OJ. Correction of the protruding deformed ear. Br J Plast Surg. 1952;5(3):187-96. 36. Converse JM, Nigro A, Wilson FA, et al. A technique for surgical correction of lop ears. Plast Reconstr Surg. 1955; 15:411-8. 37. Converse JM, Wood-Smith D. Technical details in the surgical correction of lop ear deformity. Plast Reconstr Surg. 1963;31:118-28. 38. Farrior RT. A method of otoplasty. Arch Otolaryngol. 1959; 69:400-8. 39. Pitanguy Y, Rebello C. Ansiform ears-correction by ‘‘island’’ technique. Acta Chir Plast. 1962;4:267-77. 40. Mustardé JC. The correction of prominent ears using simple mattress sutures. Br J Plast Surg. 1963;16:170-8. 41. Mustardé JC. The treatment of prominent ears by buried mattress sutures: a ten-year survey. Plast Reconstr Surg. 1967;39(4):382-6. 42. Mustardé JC. Results of otoplasty by the author’s method. In: Goldwyn RM (Ed.). Long-Term Results in Plastic and Reconstructive Surgery. Boston: Little Brown; 1980;139-44. 43. Spira M, Hardy SB. Mustarde otoplasty: A critical second look. In: Marchac D and Hueston JT (Eds). Transactions of the Sixth International Conference of Plastic and Reconstructive Surgery. Paris: Masson; 1975;297-9. 44. Kaye BL. A simplified method for correcting the prominent ear. Plast Reconstr Surg. 1967;40(1):44-8. 45. Tramier H. Personal approach to treatment of prominent ears. Plast Reconstr Surg. 1997;99(2):562-5. 46. Horlock N, Misra A, Gault DT. The postauricular fascial flap as an adjunct to Mustardé and Furnas type otoplasty. Plast Reconstr Surg. 2001;1086:1487-90; discussion 1491. 47. Adamson PA, McGraw BL, Tropper GJ. Otoplasty: Critical review of clinical results. Laryngoscope. 1991;101(8):883-8. 48. Messner AH, Crysdale WS. Otoplasty. Clinical protocol and long-term results. Arch Otolaryngol Head Neck Surg. 1996; 122(7):773-7. 49. Tan O, Atik B, Karaca C, et al. A new instrument as cartilage scorer for otoplasty and septoplasty: Adson-Brown forceps. Plast Reconstr Surg. 2005;115(2):671-2. 50. Di cio D, Castagnetti F, Baldassarre S. Otoplasty: anterior abrasion of ear cartilage with dermabrader. Aesthetic Plast Surg. 2003;27(6):466-71.

51. Azuara E. Aesthetic otoplasty with remodeling of the antihelix for the correction of the prominent ear: criteria and personal technique. Arch Facial Plast Surg. 2000;2(1):57-61. 52. Gibson T, Davis W. The distortion of autogenous cartilage grafts: Its causes and prevention. Br J Plast Surg. 1958;10:257. 53. Fry HJ. Interlocked stresses in human nasal septal cartilage. Br J Plast Surg. 1966;19(3):276-8. 54. Stenstroem SJ. A “natural” technique for correction of congenitally prominent ears. Plast Reconstr Surg. 1963; 32:509-18. 55. Chongchet V. A method of antihelix reconstruction. Br J Plast Surg. 1963;16:268-72. 56. Stenstrom SJ, Heftner J. The Stenstrom otoplasty. Clin Plast Surg. 1978;5(3):465-70. 57. Qureshi TR, Hurren JS, Gourlay T. The effectiveness of scoring and bipolar diathermy on ear cartilage behavior: ex vivo study. Ann Plast Surg. 2007;58(3):321-7. 58. Heftner J. Follow-up study on 167 Stenstrom otoplasties. Clin Plast Surg. 1978;5:470. 59. Calder JC, Naasan A. Morbidity of otoplasty: a review of 562 consecutive cases. Br J Plast Surg. 1994;47(3):170-4. 60. Ohlsen L, Verdung S. Reconstructing the antihelix of protruding ears by perichondroplasty: a modified technique. Plast Reconstr Surg. 1980;65:753-62. 61. Johnson PE. Otoplasty: shaping the antihelix. Aesthetic Plast Surg. 1994;18(1):71-4. 62. Pilz S, Hintringer T, Bauer M. Otoplasty using a spherical metal head dermabrader to form a retroauricular furrow: five year results. Aesthetic Plast Surg. 1995;19:83-91. 63. Epstein JS, Kabaker SS, Swerdloff J. The ‘‘electric’’ otoplasty. Arch Facial Plast Surg. 1999;1(3):204-7. 64. Wright WK. Otoplasty goals and principles. Arch Otolaryngol. 1970;92:568-72. 65. Scrimshaw GC. Otoplasty by abrasion, sculpture, and fixation. Arch Otolaryngol. 1977;103(10):579-81. 66. Nolst Trenité GJ. Otoplasty: a modified anterior scoring technique. Facial Plast Surg. 2004;20(4):277-85. 67. Bulstrode NW, Huang S, Martin DL. Otoplasty by percutaneous anterior scoring. Another twist to the story: a long-term study of 114 patients. Br J Plast Surg. 2003; 56(2):145-9. 68. Fritsch MH. Incisionless otoplasty. Facial Plast Surg. 2004; 20(4):267-70. 69. Yugueros P, Friedland JA. Otoplasty: the experience of 100 consecutive patients. Plast Reconstr Surg. 2001;108(4):104551 discussion 1052–3. 70. Kompatscher P, Schuler CH, Clemens S, et al. The cartilagesparing versus the cartilage-cutting technique: a retrospective quality control comparison of the Francesconi and Converse otoplasties. Aesthetic Plast Surg. 2003; 27(6):446-53. 71. Strasser EJ. An objective grading system for the evaluation of cosmetic surgical results. Plast Reconstr Surg. 1999; 104(7):2282-5. 72. Panettiere P, Marchetti L, Accorsi D, et al. Otoplasty: a comparison of techniques for antihelical defects treatment. Aesthetic Plast Surg. 2003;27(6):462-5.

The Surgical Technique of Otoplasty 21 73. Tan KH. Long-term survey of prominent ear surgery: A comparison of two methods. Br J Plast Surg. 1986;39(2): 270-3. 74. Hyckel P, Schumann D, Mansel B. Method of Converse for correction of prominent ears: comparison of results. Acta Chir Plast. 1990;32(3):164-71. 75. Owens N, Delgado DD. The management of outstanding ears. South Med J. 1965; 58:32-3. 76. Furnas DW. Correction of prominent ears with multiple sutures. Clin Plast Surg. 1978; 5(3):491-5. 77. Wood-Smith D. Otoplasty. In: T. Rees (Ed.). Aesthetic Plastic Surgery. Philadelphia: Saunders; 1980;833. 78. Gosain AK, Recinos RF. A novel approach to correction of the prominent lobule during otoplasty. Plast Reconstr Surg. 2003;112(2):575-83. 79. Spira M, McCrea R, Gerow FJ, et al. Correction of the principal deformities causing protruding ears. Plast Reconstr Surg. 1969;44(2):150-4. 80. Maurice PF, Eisbach KJ. Aesthetic otoplasty: wedge excision of a flattened helix to create a helical curl. Arch Facial Plast Surg. 2005;7(3):195-7. 81. Aygit AC. Molding the ears after anterior scoring and concha repositioning: a combined approach for protruding ear correction. Aesthetic Plast Surg. 2003;27(1):77-81. 82. Elliott RA. Complications in the treatment of prominent ears. Clin Plast Surg. 1978;5(3):479-90.

83. Hackney FL. Otoplasty. Select Read Plast Surg. 2001; 9:20. 84. Georgiade GS, Riefkohl R, Georgiade NG. Prominent ears and their correction: A forty-year experience. Aesthetic Plast Surg. 19(5);19:439-43. 85. Bradbury ET, Hewison J, Timmons MJ. Psychological and social outcome of prominent ear correction in children. Br J Plast Surg. 1992;45(2):97-100. 86. Furnas DW. Otoplasty for prominent ears. Clin Plast Surg. 2002;292:273-88 viii. 87. Sorribes MM, Tos M. Nonsurgical treatment of prominent ears with the Auri method. Arch Otolaryngol Head Neck Surg. 2002;128(12):1369-76. 88. Tan ST, Abramson DL, MacDonald DM, et al. Molding therapy for infants with deformational auricular anomalies. Ann Plast Surg. 1997;38(3):263-8. 89. Tan ST, Shibu M, Gault DT. A splint for correction of congenital ear deformities. Br J Plast Surg. 1994;47(8):575-8. 90. Matsuo K, Hirose T, Tomono T, et al. Nonsurgical correction of congenital auricular deformities in the early neonate: a preliminary report. Plast Reconstr Surg. 1984;73(1):38-51. 91. Matsuo K, Hayashi R, Kiyono M, et al. Nonsurgical correction of congenital auricular deformities. Clin Plast Surg. 1990;17(2):383-95. 92. Massengill PL, Goco PE, Norlund LL, et al. Enzymatic recontouring of auricular cartilage in a rabbit model. Arch Facial Plast Surg. 2005; 7(2):104-10.

CHAPTER

2

Single Stage Pinna Reconstruction Jumroon Tungkeeratichai

INTRODUCTION Microtia reconstruction is one of the most challenges to the surgeon. It requires the maintenance of the threedimensional details of an ear. It is under the coverage of a two-dimensional skin surface. The result was compared with normal side.

At birth, the auricle is 66% of its adult size.4 By the age 5–6 years, it is 85% of its adult size.5 Rib cartilage is rarely of sufficient size until age 5 years or 6 years. In general, the surgeons will start surgery pinna reconstruction at the age 6 years. Dr Nagata starts his pinna reconstruction at the age 10 years and a chest circumference of at least 60 cm.

Four Stages: By Brent Technique

Below mentioned are the indications for single stage pinna reconstruction:1 • Congenital microtia • Acquired defects trauma, tumor resection, burns and animal bites

Brent uses a four-stage technique to classify the reconstruction, which are as follows:6-8 1. Stage I: Fabrication of the auricular framework with contralateral costal cartilage 2. Stage II: Lobule transposition 3. Stage III: Framework elevation 4. Stage IV: Tragus reconstruction.

SPECIFIC PREOPERATIVE

First Stage: Auricular Framework Fabrication with Contralateral Rib Cartilage

INDICATIONS

EVALUATIONS—EVALUATION OF DEGREE OF MICROTIA

Three grades, according to severity, are described in the Weerda classification:2 1. Grade I microtia represents a smaller than expected, but generally well formed pinna with recognizable landmarks. 2. Grade II microtic ears have rudimentary, misshapen pinnae. The cranial end is usually curved representing a crude helix. 3. Grade III describes the worst manifestation of microtia with severe attenuation of the pinna, which is represented only by a small nodule of misshapen tissue that distinguishes it from the anotia or a complete absence of the external ear.

Aguilar and Jahrsdoerfer Classification Aguilar and Jahrsdoerfer simplified the classification into the following three categories (Figs 1A to C):3 1. Grade I: All anatomic subunits present, but misshapen. 2. Grade II: Anatomic subunits either deficient or absent. 3. Grade III: Classic “peanut ear” and anotia (Grade IV of Marx).

A template is made by placing a piece of X-ray film against the normal ear in the unilateral cases or the patient’s ear in bilateral cases by tracing anatomic landmarks. The contralateral 6th, 7th and 8th costal cartilages are usually harvested. The base of the framework is carved from the synchondrosis of the 6th and 7th rib cartilage. The helix is carved from the “floating” 8th rib cartilage. The helix is then sutured to the base with 30 nylon suture. The fabricated framework is then positioned in a subcutaneous pocket through an incision at the posterior and inferior border of the vestige. An extra piece of cartilage is also banked either in a pocket posterior to where the framework is placed to be used in the Stage III for improved ear projection. Two mini suction drains are placed and left for 7 days (Figs 2A to H).

Second Stage: Lobule Transposition This is performed 3 months after the Stage I procedure. The lobule is mobilized as an inferiorly based tissue flap and rotated to receive the end of the framework (Z-plasty fashion) (Figs 3A to F).

Third Stage: Auricular Framework Elevation This is performed 3 months after the Stage II procedure. An incision is made 5 mm from the margin of the rim.

Single Stage Pinna Reconstruction 23

A

B

Figs 1A to C: Aguilar and Jahrsdoerfer Classication.

C

Dissection is carried over the capsule of the posterior surface of the construct until the correct amount of projection is achieved. The backed piece of cartilage is placed between the framework and the mastoid to stabilize the ear position. A split thickness skin graft is used to cover the back of the elevated cartilage framework (Figs 4A to D).

Fourth Stage: Tragus Construction This is performed 3 months after the Stage III procedure. A composite skin/cartilage graft is taken from the anterolateral conchal surface of the normal ear. A J-shaped incision is made along the posterior tragal margin. The composite graft is placed through the incision and positioned so that

(A) Grade I; (B) Grade II; (C) Grade III

it produces both projection of the tragus and cavitation of the retrotragal hollow. Soft tissue is also removed from the new concha to deepen the concha bowl. The shadow of the neotragus imitates an external auditory canal (Figs 5A to F).

Nagata Technique Nagata’s technique involves the following two stage procedures:9 1. Stage I: Fabrication of auricular framework from ipsilateral costal cartilage, tragus reconstruction and lobule transposition 2. Stage II: Framework elevation

24 Otology and Lateral Skull Base

A

B

C

D

E

F

G

H

Figs 2A to H: First Stage: Auricular Framework Fabrication with Contralateral Rib Cartilage

Stage I: Fabrication of Auricular Framework, Tragus Reconstruction and Lobule Transposition Dr Nagata started his pinna reconstruction at the age 10 years and a chest circumference of at least 60 cm. Ipsilateral costal cartilages of the 6th, 7th, 8th and 9th ribs are harvested. The base of the framework is carved from the synchondrosis of 6th and 7th ribs. The helix and crus helix are carved from the 8th rib. The 9th rib is used to construct the superior crus, the inferior crus and the antihelix. A subcutaneous pocket is dissected through this incision. The central portion of the posterior skin flap is not elevated to augment blood supply to the skin flap. The framework is then placed in the pocket. The posterior flap is then advanced to suture to the anterior tragal flap and the lobule is transposed by assembling the flaps

in the Z-plasty fashion. Bolsters are used to approximate skin flaps to the framework, and they are left in place for 2 weeks (Figs 6A to C).

Stage II: Framework Elevation Six months after the Stage I, a crescent-shaped piece of cartilage is harvested from the 5th rib through the previous chest incision. An incision is made 5 mm posterior to the margin of the construct. The framework is elevated and held in place by wedging the newly harvested cartilage into position. A temporoparietal fascia (TPF) flap is elevated through a new scalp incision and tunneled subcutaneously to cover the posterior surface of the cartilage graft and reconstructed auricle. The back of the framework is then covered with ultradelicate split thickness skin graft harvested freehand from the occipital scalp (Figs 7A to F).

Single Stage Pinna Reconstruction 25

A

B

E

F

A

C

D

Figs 3A to F: Lobule Transposition

B

C

Figs 4A to D: Auricular Framework Elevation

D

26 Otology and Lateral Skull Base

A

B

C

D

E

F

Figs 5A to F: Tragus Reconstruction

Single Stage Pinna Reconstruction 27

A

B

C Figs 6A to C: Fabrication of auricular framework from ipsilateral costal cartilage, tragus reconstruction and lobule transposition

28 Otology and Lateral Skull Base

A

B

C

D

E

F Figs 7A to F: Framework elevation

COMPLICATIONS Below mentioned are the complications for single stage pinna reconstruction: • Flap necrosis (14%) • Anterior chest wall deformity • Unnaturally thick ear • High extrusion rate may be due to the use of wire sutures (8%).

Ear Reconstruction Site • Exposure of the framework • Resorption of the framework

Cartilage Donor Site • Immediate problem: Pneumothorax, atelectasis • Delayed problem: Anterior chest wall deformity, scarring at scalp flaps incision when access to TPF flaps. Dr Nagata has recommended keeping the posterior perichondrium intact to help prevent this problem.9

The complications at the ear reconstruction site mainly consist of extrusion of the framework secondary to skin flap necrosis and resorption of the framework. If the framework is exposed, early intervention with local skin and fascial flaps is usually used to salvage the recons­truction. The temporal fascia is a potential salvage resource. Also, suture is placed too tightly or placement of the framework in a scarred manner; ischemic bed may predispose the cartilage to resorption.9

SURGICAL STEPS FOR SINGLE

STAGE PINNA RECONSTRUCTION

Below mentioned are the eight steps for single stage pinna reconstruction: 1. Preoperation and preparation 2. Local anesthesia 3. Implant preparation 4. Harvesting skin grafts 5. Elevation scalp flaps, elevating TPF flaps, lobule transposition

Single Stage Pinna Reconstruction 29 6. Implant placement 7. Suture skin grafts 8. Dressing

Preoperation and Preparation The superior most aspect of the helix generally sits at the level of the supraorbital rim (tail of the eyebrow), whereas the inferior most aspect of the lobule corresponds to the base of the columella. The average width of the ear is 55% of its length (55–65 mm). The ear is positioned at 15°–20° posterior to the vertical axis. The auriculocephalic angle is between 25° and 35°.10-12 Before sterile preparation, shave the hair 18 cm from the ear lobule remnant or 12 cm above the line of the upper part of helix. Use Doppler technique and mark the superficial temporal artery, and its anterior and posterior branch that will be contained in the TPF flap (Figs 8 and 9A and B).13

Local Anesthesia Infiltrate the incision lines in the subdermal plane with a 0.5% lidocaine local anesthetic with 1:200,000 epinephrine solution, concha flap, Z-plasty for lobule remnant and vertical Y-shaped or Z-shaped scalp flaps incision for access to TPF (Fig. 10). Fig. 8: Anatomy layer of Temporoparietal fascia, Deep temporal fascia

Fig. 9A: Preoperation and Preparation

Fig. 9B: Incision

30 Otology and Lateral Skull Base Implant Preparation Fix the extended ear base and helical rim implants three points with 3-0 nylon, then soak in betadine solution and prevent contamination (Figs 11A and B).

Harvesting the Abdominal, Chest Wall or Inguinal Skin Grafts The abdominal, chest wall or inguinal skin graft can be harvested by full thickness skin grafts (Figs 12A and B).

Elevation Scalp Flaps, Elevating Temporoparietal Fascia Flaps, Lobule Transposition14 Raise the scalp flaps (Y- or Z-shaped) for TPF access using a Colorado needle fine tip cautery or using a blunttipped Steven’s scissors subfollicular plane. Develop a plane between the skin and superficial TPF requires size 12 cm wide × 11 cm high superficial TPF flap, including the ­superficial artery, including the anterior and posterior branches of the temporal artery. Avoid injury the ­temporal branch of the facial nerve in the line midway of lateral eyebrow and hair bearing temple (1.5 cm from the tail of eyebrow or 2 cm from the orbital rim). Lifting of TPF from the deep temporal fascia is done with blunt-tipped Steven’s scissors. Rotate the lobular remnant to posterior with Z-plasty technique (Figs 13A to E).

Implant Placement Raise TPF flap (thin 12 cm wide × 11 cm high) to cover the implant framework. After placing mini drain underneath the implant framework, the entire implant framework must be covered with the TPF flap. Then suture TPF flap together and apply low wall suction to the drain intraoperatively after the flap is draped over the implant. If not seal, check the leak with normal saline, then suture with 4-0 Vicryl. Place mini drain one more under the scalp flaps, then suture the scalp flaps with 5-0 nylon (Figs 14A and B).

Suture Skin Grafts

Fig. 10: Local Anesthesia at incision line

A

The first, full thickness skin graft (contralateral postauricular) is used to cover the outside surface of the TPF covered implant framework. The second, skin graft (from

B Figs 11A and B: Implant Preparation

Single Stage Pinna Reconstruction 31

A

B Figs 12A and B: Harvesting the Abdominal, Chest Wall or Inguinal Skin Grafts

A Fig. 13A

32 Otology and Lateral Skull Base

B

C

D

E Figs 13A to E: Elevation Scalp Flaps, Elevating Temporoparietal Fascia Flaps, Lobule Transposition

A

B Figs 14A and B: Implant Placement

Single Stage Pinna Reconstruction 33 chest wall, inguinal or abdominal) is used for the posterior surface of the TPF covered implant framework. Both grafts are sutured together with 5-0 nylon. Suture the drains into place (Figs 15A to D).

Dressing After checking the air leak, the drain suction negative pressure works. Terramycin ointment is applied over the entire graft and suture lines. The whole framework is then covered with sofra-tulle, and two small pieces of cotton

soaked in terramycin ointment, are placed into the antihelix and conchal areas. Both mini suction drains are maintained for 7–10 days. The drains are removed when the sutures are completely removed after 7–10 days (Fig. 16).

POSTOPERATION Postoperation left microtia Grade III with single stage pinna reconstruction technique has been shown in Figures 17A to C.

A

B

C

D Figs 15A to D: Suture Skin Grafts

34 Otology and Lateral Skull Base

A

B Fig. 16: Dressing

REFERENCES 1. Romo T Reitzen SD. Aesthetic microtia reconstruction with Medpor. Facial Plast Surg. 2008;24(1):120-8. 2. Weerda H. Classification of congenital deformities of the auricle. Facial Plast Surg. 1988;5(5):385-8. 3. Strasnick B, Haynes DS. Otologic history and physical examination of the ear. In: Canalis RF, Lambert PR (Eds). The Ear: Comprehensive Otology. Philadelphia, PA: Lippincott Williams & Wilkins; 2000. pp. 157-66. 4. Beahm EK, Walton RL. Auricular reconstruction for mict­ rotia: part I. Anatomy, embryology, and clinical evaluation. Plast Reconstr Surg. 2002;109(7):2473-82; quiz following 2482. 5. Romo T Presti PM, Yalamanchili HR. Medpor alternative for microtia repair. Facial Plast Surg Clin North Am. 2006;14(2):129-36, vi. 6. Brent B. Technical advances in ear reconstruction with autogenous rib cartilage grafts: personal experience with 1200 cases. Plast Reconstr Surg. 1999;104(2):319-34; discussion 335-8.

C Figs 17A to C: Postoperation

7. Brent B. Microtia repair with rib cartilage grafts: a review of personal experience with 1000 cases. Clin Plast Surg. 2002;29(2):257-71, vii. 8. Tanzer RC. Microtia—a long-term follow-up of 44 reconstructed auricles. Plast Reconstr Surg. 1978;61(2):161-6. 9. Walton RL, Beahm EK. Auricular reconstruction for microtia: Part II. Surgical techniques. Plast Reconstr Surg. 2002;110(1):234-49; quiz 250-1, 387. 10. Sclafani AP, Mashkevich G. Aesthetic reconstruction of the auricle. Facial Plast Surg Clin North Am. 2006;14(2):103-16, vi. 11. Tolleth H. A hierarchy of values in the design and construction of the ear. Clin Plast Surg. 1990;17(2):193-207. 12. Quatela VC, Thompson SK, Goldman ND. Microtia reconstruction. Facial Plast Surg Clin North Am. 2006;14(2): 117-27, vi. 13. Park C, Lew DH, Yoo WM. An analysis of 123 temporo­ parietal fascial flaps: anatomic and clinical considerations in total auricular reconstruction. Plast Reconstr Surg. 1999;104(5):1295-306. 14. Reinisch JF, Lewin S. Ear reconstruction using a porous polyethylene framework and temporoparietal fascia flap. Facial Plast Surg. 2009;25(3):181-9. Epub 2009.

The Surgical Technique of Otoplasty 35

CHAPTER

3

Treatment of Earlobe Keloids Stahl Shy, Haik Josef, Goldan Oren, Eyal Winkler

INTRODUCTION A keloid is defined as a scar, which extends beyond the confines of the original wound into clinically normal skin.1,2 The term is coined from the Greek word cheloides, which means “crab’s claw”. Keloids can appear months or even years after the primary injury and rarely regress over time.3 Earlobe keloids have a thick glassy crimson appearance,4 and are most often the result of ear piercing (76.3%),5 particularly performed after the age of 11,6 with an incidence of approximately 2.5%.7 Other causes include surgery (i.e., otoplasty), infection, excessive wound tension, burns or other trauma to the earlobe skin.8 The primary risk factor for keloid formation is dark pigmentation, and it has been estimated that 15% to 20% of African Americans,9 Hispanics and Orientals suffer from keloids.2,10 Additional risk factors are detailed in Table 1. Apart from the aesthetic disfigurement, (Fig. 1) accompanying symptoms include pigmentation, pruritus and pain.2,11

regulating the wound healing process, resulting in excessive disorganized collagen deposition in the dermis and subcutaneous tissues, forming persistent firm nodules and plaques that extend beyond the margin of the initiating trauma.13 Histological findings show a normal epidermal layer, abundant vasculature, increased mesenchymal density, thickened dermis and an increased inflammatory cell infiltrate.14 Keloid fibroblasts show an imbalance of normal wound healing processes,8 by further increasing their already augmented rate of collagen synthesis as a response to platelet-derived growth factor and transforming growth factor β (TGF-β),13,15 and a decreased capacity for fibrinolysis15 and fibrin clot degradation.16

PATHOLOGY Keloids are a unique phenomenon in humans, as the wound healing process in other species presents significant differences when compared with human scarring.12 The underlying pathology is lack of a control mechanism Table 1: Keloid risk factors2,4 • • • • • • •

Darkly pigmented skin–15 fold risk Asian or Hispanic descent Familial/genetic predisposition Age (10–30 years) Elevated hormone levels (e.g. pregnancy, puberty) Location: Chest, shoulders, earlobes, cheeks Trauma type (burns, acne, ear piercing, chickenpox, vaccinations) • Delayed wound healing

Fig. 1: The esthetic disfigurement caused by a large keloid

36 Otology and Lateral Skull Base The cytokine profile is of high levels of transforming growth factor β1 and β2, vascular endothelial growth factor, connective tissue growth factor, platelet derived growth factor alpha, and interleukins 6 and 8.8

TREATMENT In order to avoid keloids in predisposed patients, non­essential cosmetic surgery should be avoided, incisions should be placed along skin tension lines, and wounds should be closed without tension.4 When considering earlobe keloids treatment, one should keep in mind that recurrence, defined as a growing pruritic nodular scar,3 or any redness or elevation of a scar, is higher than other sites after resection, either with or without adjuvant treatment.4 Current treatment modalities include pressure earrings and silicone sheets or gels, intralesional corticosteroid, 5-fluorouracil and interferon injections, cryosurgery, LASER excision, radiotherapy, and surgical excision.1,8 Currently, there is no criterion standard for the treatment of keloids. Primary excision alone results in recurrence rates ranging between 40% to 50%,17 therefore preferring a combination of modalities, most common of which are excision followed by steroid injections or radiotherapy. Silicone elastomer sheets act by heating, hydrating and increasing the oxygen tension of the occluded scar, causing it to soften and flatten. The sheets should be worn for 12 hours to 24 hours daily, for a period of 3 months.17 Corticosteroids are the first line monotherapy in cases of small keloids. Their action can be described as follows: • Suppression of inflammation and mitosis, while increasing vasoconstriction in the scar. • Inhibition of fibroblasts and collagen synthesis by inhibiting transforming growth factor β expression18 • Increment in collagenase activity by inhibition of α2-macroglobulin.19 • Reduction in fibroblasts proliferation by suppression of vascular endothelial growth factor.20 The treatment is performed by intralesionally injecting 10 mg/ml to 40 mg/ml triamcinolone acetonide (Kenalog, Bristol-Myers Squibb, New York, NY) into the papillary dermis once every 2–3 weeks for a period of up to 6 months.4,21 Addition of lidocaine to the injection can greatly reduce the pain, which accompanies the injection. As a sole treatment, intralesional corticosteroids carry a recurrence rate of 9% to 50%.10 Potential side effects include infection, skin atrophy (particularly when injected into the subcutaneous tissue), telangiectasia and hypopigmentation.1,2,18 The injection of steroids following surgery reduces the recurrence rate to less than 20%,22

and in these cases, sutures should be left in place longer to prevent wound dehiscence. In recent years, the application of imiquimod 5% (Aldara), an immune response modulator, following surgery, has been investigated. The cream is applied on alternate nights for 8 weeks, with a reported recurrence rate of 28%.23 Adverse effects include irritation and hyperpigmentation. Cryosurgery is performed by freezing the lesion with liquid nitrogen, causing cell and microvascular damage, followed by selective tissue necrosis, sloughing and flattening.19 Two to twelve cycles are performed every 2–3 weeks until resolution of the keloid. Side effects include hypopigmentation, skin atrophy and cartilage damage.4 Several techniques have been described for keloid excision; the most common being wedge resection, where the incisions are made through normal, unaffected earlobe tissue. This technique best suits dumbbell-shaped and horseshoe-shaped lesions that involve the central lobe of the lateral rim.8 However, with keloids reaching half the size of the earlobe, acceptable cosmetic outcome diminishes. Another technique, keloid core excision, involves excising the fibrous core of the keloid while preserving the overlying skin to use as a flap to cover the defect.8 The logic being initiating the wound healing process from the stage of scar maturation, thereby attempting to avoid the primary forces that have led to keloid formation. Recently described is the keloid fillet flap in which the skin over the keloid is dissected from the keloid mass, followed by primary skin closure.24 In large lesions, the use of skin grafts of postauricular flaps may be favored.4 During excision, careful attention should be paid to preserve as much normal tissue as possible. The defect is usually repaired with a 5-0 or 6-0 non-absorbable suture, such as nylon, which are removed after 10–14 days. No deep stitches are used in closure, to limit foreign body exposure. Postoperative pressure therapy, in the form of earrings, has been recommended as an adjunct modality. Earrings should be worn for 12–24 hours daily for a prolonged period of time. It has been hypothesized that earring decrease scar hydration, resulting in mast cell stabilization and a decrease in neovascularization and extracellular matrix production.4 Radiotherapy destroys activated fibroblasts, connective tissue stem cells and acute inflammatory cells;4,10,25 administered following keloid excision, it can abate the exaggerated wound healing process to normal levels.26 The literature suggest 8 Gy to be at the lower end of any recommended dose range, and doses up to 40 Gy have been described in either single or multiple fractions delivered within 48 hours of surgery,1 though no one technique

Treatment of Earlobe Keloids 37 or dose fractionation schedule has been accepted as optimal. Alone, it carries a variable response rates, ranging between 10% to 94%,25,27 and is best suited as an adjuvant to surgical treatment, in which a 2% to 40% recurrence rate has been reported.1 The author has recently reported a novel technique, where radiation is given a day prior to surgery and a day following surgical excision of the keloid scar.28 The advantages gained are preoperative block of the postoperative stimulus of the multipotent cells to differentiate and proliferate, better delineation of the target volume, and reduction of irradiation exposure of the normal surrounding tissues. Irradiation of auricular keloids may cause cancer of the salivary glands, such as the parotid glands, which are located close to the ear,29 particularly squamous cell carcinoma, when large doses are used. However, reports regarding a direct relationship between radiation induced malignancy following earlobe keloid treatment are lacking,4 and only five potential cases of radiation induced malignancy and one documented case have been described following radiotherapy treatment for keloids in other locations.30 Thus, the calculated crude risk of radiation induced malignancy for the treatment of keloids is 1 in 1348.1 This small risk must always be considered when recommending low dose adjuvant radio­therapy, and it is best avoided in pediatric and pregnant patients.5 Adverse effects include skin atrophy, telangiectasia, hyperpigmentation, pruritus, erythema and subcutaneous fibrosis.1,4 These increase with an increase in dose per fraction. In summary, when treating earlobe keloids, attention should focus on the size of the keloid scar and the period of time the keloid has been present. Primary treatment of recent, small earlobe keloids should focus on intralesional steroid injections accompanied by pressure earrings. In contrast, long-term or recurrent large-sized keloids should preferably be treated by combined excision and adjuvant radiotherapy. Additional treatment modalities should be considered when these have failed or resulted in recurrence (Table 2). Table 2: Risk factors for recurrence1,19 • Keloid > 2 cm in size • Men • Family history • Infectious, chemical or thermal etiology • Previous treatment history (6.92 increased odds ratio)31 • Closure with tension • Low growth rate32 • Long duration prior to treatment31 • High body mass index31

REFERENCES 1. Dinh Q, Veness M, Richards S. Role of adjuvant radiotherapy in recurrent earlobe keloids. Australas J Dermatol. 2004;45(3):162-6. 2. Juckett G, Hartman-Adams H. Management of keloids and hypertrophic scars. Am Fam Physician. 2009;80(3):253-60. 3. Cosman B, Wolff M. Bilateral earlobe keloids. Plast Reconstr Surg. 1974;53(5):540-3. 4. Froelich K, Staudenmaier R, Kleinsasser N, et al. Therapy of auricular keloids: review of different treatment modalities and proposal for a therapeutic algorithm. Eur Arch Otorhinolaryngol. 2007;264(12):1497-508. 5. Recalcati S, Caccialanza M, Piccinno R. Postoperative radiotherapy of auricular keloids: a 26-year experience. J Dermatolog Treat. 2011;22(1):38-42. 6. Lane JE, Waller JL, Davis LS. Relationship between age of ear piercing and keloid formation. Pediatrics. 2005;115(5): 1312-4. 7. Zuber TJ, DeWitt DE. Earlobe keloids. Am Fam Physician. 1994;49(8):1835-41. 8. Music EN, Engel G. Earlobe keloids: a novel and elegant surgical approach. Dermatol Surg. 2010;36(3):395-400. 9. Oluwasanmi JO. Keloids in the African. Clin Plast Surg. 1974;1(1):179-95. 10. Niessen FB, Spauwen PH, Schalkwijk J, et al. On the nature of hypertrophic scars and keloids: a review. Plast Reconstr Surg. 1999;104(5):1435-58. 11. Lee SS, Yosipovitch G, Chan YH, et al. Pruritus, pain, and small nerve fiber function in keloids: a controlled study. J Am Acad Dermatol. 2004;51(6):1002-6. 12. Ramos ML, Gragnani A, Ferreira LM. Is there an ideal animal model to study hypertrophic scarring? J Burn Care Res. 2008;29(2):363-8. 13. Butler PD, Longaker MT, Yang GP. Current progress in keloid research and treatment. J Am Coll Surg. 2008;206(4):731-41. 14. Atiyeh BS, Costagliola M, Hayek SN. Keloid or hypertrophic scar: the controversy: review of the literature. Ann Plast Surg. 2005;54(6):676-80. 15. Tuan TL, Nichter LS. The molecular basis of keloid and hypertrophic scar formation. Mol Med Today. 1998;4(1):19-24. 16. Tuan TL, Zhu JY, Sun B, et al. Elevated levels of plasminogen activator inhibitor-1 may account for the altered fibrinolysis by keloid fibroblasts. J Invest Dermatol. 1996;106(5):1007-11. 17. Berman B, Perez OA, Konda S, et al. A review of the biologic effects, clinical efficacy, and safety of silicone elastomer sheeting for hypertrophic and keloid scar treatment and management. Dermatol Surg. 2007;33(11):1291-302; discussion 1302-3. 18. Hamrick M, Boswell W, Carney D. Successful treatment of earlobe keloids in the pediatric population. J Pediatr Surg. 2009;44(1):286-8. 19. Kelly AP. Medical and surgical therapies for keloids. Dermatol Ther. 2004;17(2):212-8. 20. Wu WS, Wang FS, Yang KD, et al. Dexamethasone induction of keloid regression through effective suppression of VEGF expression and keloid fibroblast proliferation. J Invest Dermatol. 2006;126(6):1264-71.

38 Otology and Lateral Skull Base 21. Sherris DA, Larrabee WF Jr, Murakami CS. Management of scar contractures, hypertrophic scars, and keloids. Otolaryngol Clin North Am. 1995;28(5):1057-68. 22. Mustoe TA, Cooter RD, Gold MH, et al. International clinical recommendations on scar management. Plast Reconstr Surg. 2002;110(2):560-71. 23. Chuangsuwanich A, Gunjittisomram S. The efficacy of 5% imiquimod cream in the prevention of recurrence of excised keloids. J Med Assoc Thai. 2007;90(7):1363-7. 24. Kim DY, Kim ES, Eo SR, et al. A surgical approach for earlobe keloid: keloid fillet flap. Plast Reconstr Surg. 2004;113(6): 1668-74. 25. Lawrence WT. In search of the optimal treatment of keloids: report of a series and a review of the literature. Ann Plast Surg. 1991;27(2):164-78. 26. Flickinger JC. A radiobiological analysis of multicenter data for postoperative keloid radiotherapy. Int J Radiat Oncol Biol Phys. 2011;79(4):1164-70. 27. Berman B, Bieley HC. Keloids. J Am Acad Dermatol. 1995;33 (1):117-23.

28. Stahl S, Barnea Y, Weiss J, et al. Treatment of earlobe keloids by extralesional excision combined with preoperative and postoperative “sandwich” radiotherapy. Plast Reconstr Surg. 2010;125(1):135-41. 29. Bermueller C, Rettinger G, Keck T. Auricular keloids: treatment and results. Eur Arch Otorhinolaryngol. 2010;267(4): 575-80. 30. Ragoowansi R, Cornes PG, Glees JP, et al. Ear-lobe keloids: treatment by a protocol of surgical excision and immediate postoperative adjuvant radiotherapy. Br J Plast Surg. 2001;54(6):504-8. 31. Park TH, Seo SW, Kim JK, et al. Outcomes of surgical excision with pressure therapy using magnets and identification of risk factors for recurrent keloids. Plas Reconstr Surg. 2011;128(2):431-9. 32. Rosen DJ, Patel MK, Freeman K, et al. A primary protocol for the management of ear keloids: results of excision combined with intraoperative and postoperative steroid injections. Plast Reconstr Surg. 2007;120(5):1395-400.

The Surgical Technique Preauricular of Otoplasty Sinus 39

CHAPTER

4

Preauricular Sinus Vicky S Khattar, Bachi T Hathiram, Snigdha Devane, Supriya Rode

INTRODUCTION

SURGICAL STEPS (FIGS 1 TO 6)

Congenital preauricular sinus is a malformation of the preauricular soft tissues with an incidence ranging between 0.1% and 0.9%.1 The embryological basis of this malformation is associated with a defect in the development of the first branchial arch during the 6th week of gestation. This alteration is probably due to incomplete fusion of the six auditory hillocks of His. Another hypothesis, less accredited, is that the sinus develops during embryonal auricular development from an isolated ectodermal folding.2

Topographically, the sinus is located more superficially than the temporalis fascia and the terminal cutaneous portion is very near, and often adhering to, the cartilage of the first portion of the helix.2 • Patient in supine position held tilted to opposite side • Infiltration with lignocaine 2% and adrenaline (1:200,000) around the sinus • Cannulation of sinus with a small lacrimal probe7 and injection of methylene blue dye into the tract to delineate tract of sinus • Simple sinectomy: A standard technique that includes an elliptic skin excision around the sinus opening and the dissection of its ramifications in the subcutaneous tissues under visual or palpatory guidance8,9 • Supra-auricular approach: The elliptical incision of the standard technique is extended higher upward to the preauricular and supra-auricular temporal region. This allows better surgical vision without adverse

INDICATIONS FOR SURGERY • • • •

Discharging sinus Repeated episodes of infection and abscess formation Recurrence after surgery Cosmesis or as per patient’s request.

PREOPERATIVE EVALUATION • If acutely inflamed a course of antibiotics to be given • In case of a preauricular abscess, intravenous antibiotics are given and the abscess needs to be drained • Associations have been described with renal or inner ear anomalies,3,4 so evaluation for syndromes in which the preauricular sinus is one of the clinical features5,6 is mandatory • Examination of pinna (perichondritis), external auditory canal (otitis externa) and tympanic membrane should be performed.

ANESTHETIC CONSIDERATIONS Children: The surgery is performed under general anesthesia. Adults: Local infiltration anesthesia is used with lignocaine 2% with adrenaline 1:200,000 postaurally, over preaural region and around sinus along with sedation.

Fig. 1: Incision marked around the fistula. The fistula tract

has also been injected with methylene blue, so as to help identify the tract during deeper dissection

40 Otology and Lateral Skull Base

Fig. 2: The incision is taken so as to include the

Fig. 3: A small curved scissors is used to

Fig. 4: The methylene blue dot at the opening of

Fig. 5: The final appearance after removal of the sinus.

infected skin around the tract

the tract is seen during deeper dissection

esthetic consequences. Dissection proceeds identifying the temporalis fascia medially to the sinus area. It is only this fascia that represents a medial and deep limit of dissection that continues in a medium lateral direction until reaching the helix cartilage. At the point of maximum adherence of the fistula, excision of a small portion of the cartilage is advisable.10 • Hemostasis and closure • Mastoid pressure dressing

dissect in the subcutaneous plane

Note the cartilage of the helix is exposed which forms the posterior limit of dissection, and the temporalis fascia forms the medial limit of dissection

COMPLICATIONS AND THEIR MANAGEMENT

Intraoperative Complications • Hemorrhage: This is due to injury to the superficial temporal artery. This can be controlled by electrocautery or ligation.

Preauricular Sinus 41

ACKNOWLEDGMENTS The authors are thankful to the Dean, TN Medical College and BYL Nair Charitable Hospital for granting permission to publish this chapter.

REFERENCES

Fig. 6: Subcutaneous sutures are taken following which the skin is closed with interrupted nonabsorbable sutures, or with absorbable subcuticular sutures, following which adhesive strips may be used to approximate the skin edges

Postoperative Complications • Hematoma formation: This is managed by exploration after removing few sutures and draining the hematoma and ligating the bleeding vessel usually superficial temporal artery • Infection/Perichondritis: This is managed by sending pus for culture sensitivity and starting appropriate antibiotics and local wound dressing • Recurrence: This requires a revision surgery • Keloid formation: This requires cosmetic surgery with removal of the keloid.

1. Scheinfeld NS, Silverberg NB, Weinberg JM, et al. The preauricular sinus: a review of its clinical presentation, treatment, and associations. Pediatr Dermatol. 2004;21:191-6. 2. Tan T, Constantinides H, Mitchell TE. The preauricular sinus: a review of its aetiology, clinical presentation and management. Int J Pediatr Otorhinolaryngol. 2005;69:1469-74. 3. Leung AK, Robson WL. Association of the preauricular sinuses and renal anomalies. Urology. 1992;40:259-61. 4. Wang RY, Earl DL, Ruder RO, et al. Syndromic ear anomalies and renal ultrasounds. Pediatrics. 2001;108:E32. 5. Huang XY, Tay GS, Wansaicheong GK, et al. Preauricular sinus: clinical course and associations. Arch Otolaryngol Head Neck Surg. 2007;133:65-8. 6. Smith PG, Dyches TJ, Loomis RA. Clinical aspects of the branchio-otorenal syndrome. Otolaryngol Head Neck Surg. 1984;92:468-75. 7. Coatesworth AP, Patmore H, Jose J. Management of an infected preauricular sinus, using a lacrimal probe. J Laryngol Otol. 2003;117:983-4. 8. Lam HC, Soo G, Wormald PJ, et al. Excision of the preauricular sinus: a comparison of two surgical techniques. Laryngoscope. 2001;111:317-9. 9. Baatenburg de Jong RJ. A new surgical technique for treatment of preauricular sinus. Surgery. 2005;137:567-70. 10. Prasad S, Grundfast K, Milmoe G. Management of congenital preauricular pit and sinus tract in children. Laryngoscope. 1990;100:320-1.

42 Otology and Lateral Skull Base CHAPTER

5

The Surgical Technique of Otoplasty

External Auditory Canal Obliteration Vicky S Khattar, Bachi T Hathiram

This surgery forms a part of the surgical management of glomus tumors, large temporal meningoencephaloceles and malignancies of the temporal bone. The external auditory canal (EAC) requires to be closed, or obliterated in a “cul-de-sac” manner following its resection and mastoid cavity obliteration after a radical mastoidectomy has been performed to remove the tumor or seal a large tegmen defect following the removal of a meningoencephalocele.

STEPS OF SURGERY The steps of surgery have been discussed in Figures 1 to 30.

Fig. 1: The mastoid cortex is exposed and the mucoperiosteal flap is elevated

Fig. 2A: Schematic diagram depicting meatotomy with subsequent exposure of the tumor in the external auditory canal

Fig. 2B: Meatotomy is performed and the glomus tumor can be seen in the external auditory canal. In such cases, it may sometimes be wise to perform the meatotomy with a scissors, in order to avoid trauma to vascular tumors such as these

External Auditory Canal Obliteration 43

Fig. 3: The meatotomy is performed till the anterior canal wall skin is seen easily

Fig. 4: The incision is taken on the anterior external auditory canal wall with a blade, at the same level as the meatotomy

Fig. 5: It is important for the incision to be taken through

Fig. 6: Dissecting the skin from the cartilage of

only the skin of the external auditory canal

the posterior canal wall

Fig. 7A: Schematic diagram depicting the anterior canal wall skin and separating the skin of the external auditory canal

44 Otology and Lateral Skull Base

Fig. 7B: Fashioning a second flap of mucoperiosteum lateral

Fig. 8: The two flaps are now seen distinctly

Fig. 9: The first suture is passed through the anterior canal wall skin, lateral to the incision on the canal wall

Fig. 10A: Schematic diagram depicting the first

to the previously fashioned flap, which will eventually form the second layer of closure of the external auditory canal

layer of EAC skin closure

Fig. 10B: One must make sure that the “bite” of the suture through the skin is large enough, to prevent any “cut-through”

External Auditory Canal Obliteration 45

Fig. 11: The same suture should then be passed through the

Fig. 12: The second suture taken through the anterior

Fig. 13: It is then passed through the posterior flap

Fig. 14: The third and final suture is then taken

medial flap of skin, to approximate the anterior and posterior canal walls

canal wall, similar to the first one

Fig. 15: A hemostat is passed through the external auditory canal from the outside, and used to grasp all the three sutures and deliver them to the outside of the external auditory canal

46 Otology and Lateral Skull Base

Fig. 16: One by one all the three sutures are carefully sorted out in their respective pairs

Fig. 17: All the three sutures seen delivered out of the external auditory canal and sorted in their pairs

Fig. 18: One by one the sutures are knotted

Fig. 19A: Schematic diagram showing the cul-de-sac closure as seen from the lateral aspect

Fig. 19B: All the three sutures are tied

External Auditory Canal Obliteration 47

Fig. 20: All three sutures are cut. Thus the first layer of

Fig. 21: The appearance of the first layer of closure as

closure of the external auditory canal is now complete

seen from the subcutaneous aspect

Fig. 22: The lateral musculoperiosteal flap is now used to

Fig. 23: Once again, a large bite is taken to

form the second layer of closure. The sutures are here seen to be taken first through the flap

prevent any “cutting through”

Fig. 24: The second bite of the suture goes through the exposed subcutaneous tissue, just medial to the skin incision on the anterior canal wall

48 Otology and Lateral Skull Base

Fig. 25: As seen here, this will form the

Fig. 26: The suture is knotted

second layer of closure

Fig. 27: The second stitch is now taken

Fig. 28: The second suture when approximated will isolate the obliterated external auditory canal from the mastoid cavity, as seen in Figure 29

Fig. 29: The sutures being knotted

Fig. 30: The final appearance after both layers are secured

CHAPTER

6

Meatoplasty Vicky S Khattar, Bachi T Hathiram

DEFINITION

SURGERY

Meatoplasty can be defined as the surgical procedure of widening the external auditory meatus.

This chapter deals with the surgical steps of meatoplasty performed as a part of the CWD mastoidectomy. It is a known fact that the presence of a large or more appropriately, “adequate sized” external auditory meatus is an essential prerequisite to a successful outcome of a CWD mastoidectomy operation. The external auditory meatus is lined by the following, from superficial layer to deep: skin, cartilage, subcutaneous tissue and bone. Whatever the superficial approach used, (endaural or postaural), in case of a CWD tympanomastoidectomy (open technique), the otologist must ensure good ventilation of the entire cavity. This can only be achieved by performing an adequately sized meatoplasty (Fig. 1).

INDICATIONS • As part of the canal-wall-down (CWD) tympanomastoidectomy procedure to ensure a widened, wellaerated, self-cleansing and dry external auditory canal which lends itself to easy examination and aural toilet. • Conchomeatoplasty is performed in some cases of intractable chronic otitis externa.1 • As a part of the surgery performed for congenital meatal atresia [The three basic steps in the correction of complete atresia of the external canal include: (1) Meatoplasty, (2) Canaloplasty and tympanoplasty, and (3) Grafting of the newly created external auditory canal].2 • As a part of the surgical procedure performed for the management of severe external auditory meatus exostoses (This requires a canaloplasty and then, since the resultant external auditory canal is wider than before, it is followed by a meatoplasty).3

Principle of Surgery The eventual outcome of a CWD/open technique is a cavity lined by epithelium, and skin needs to be aerated

SPECIFIC PREOPERATIVE EVALUATION

Depending on the indication for performing the meatoplasty, the patient is evaluated. A pure tone audiometric assessment of the hearing status and a computed tomography (CT) scan of the temporal bone are usually merited in most cases.

ANESTHETIC CONSIDERATIONS There are no specific anesthetic considerations related to the surgical procedure, but the same may be specific to the patient.

Fig. 1: Clinical photograph of an adequately sized meato­ plasty in a postoperative case (1 year later) of canal-walldown (CWD) tympanomastoidectomy

50 Otology and Lateral Skull Base

Fig. 2:  A high resolution computed tomographic scan of the

Fig. 3:  The external auditory meatus of the

postoperative (1 year later) mastoid cavity in a canal-walldown (CWD) mastoidectomy showing an adequately sized meatoplasty, resulting in a well-aerated cavity

patient is shown before meatoplasty

A

B Figs 4A and B:  A small anteriorly-based flap is elevated to visualize the mastoid cortex and bony external auditory canal

directly at its surface to function normally; otherwise, it tends to get modified and forms a cholesteatoma. If “V” stands for the “volume of air” circulating and “S” stands for the “surface area of skin” in contact with the circulating air, then we as otologists must ensure that “V” is greater than “S” for a successful outcome of our open technique surgery (Fig. 2). In a majority of cases, the cavity after surgery is not too large and hence, an adequate meatoplasty ensures good aeration of the cavity. However, if the cavity is too large, the surgeon can diminish the size by a partial obliterative procedure and reduce the “S” to suit the “V.”4

A variety of techniques for meatoplasty have been described, ranging from a simple conchomeatal flap, to elaborate trimming of the conchal cartilage with a “threeflap-technique” for suturing. However, one basic anatomic principle needs to be kept in mind: the skin of the posterior meatal wall should, if possible, be conserved since it has a rich blood supply and will assist in healing and epithelialization. It is referred to as the “cutis strip” (House, 1960) or the “vascular strip” (Plester, 1963). The meatal skin may be pedicled superiorly or inferiorly or on the tympanic membrane as in the Lempert’s tympanomeatal flap.

Meatoplasty 51

A

B Figs 5A and B:  A meatotomy incision is taken at the level of the spine of Henle. This incision is a posterior incision parallel to the tympanic annulus extending from the 12 o’clock to 6 o’clock positions

Fig. 6:  The lower limb of the meatotomy incision is

Fig. 7:  Similarly, the upper limb is also extended

extended to cut through the conchal cartilage

Steps of the Surgical Procedure The steps of surgical procedures are discussed in Figures 3 to 10 as follows:

In the last 20 years, the authors have performed more than approximately 3,200 open technique mastoid surgeries and seen a stenosis of meatoplasty in not more than 100 cases.

52 Otology and Lateral Skull Base

Fig. 8:  The flap with a part of the concha is now excised in full thickness

Fig. 9:  A vertical incision is then taken through the remnant of the concha to fashion superior and inferior flaps

Fig. 10:  An adequately sized meatoplasty is the result

Fig. 11: The Koerner’s flap is constructed by making

when the flaps are sutured to the postauricular soft tissues

OTHER TECHNIQUES OF MEATOPLASTY

Meatoplasty Using a Koerner’s Flap Meatoplasty using a Koerner’s flap is discussed in Figure 11.

longitudinal incisions in the skin of the external auditory canal at 12 o’clock and 6 o’clock and connecting them with a posterior incision parallel to the tympanic annulus. The incisions at the 12 o’clock and 6 o’clock are then extended from the posterior annular incision in the external auditory canal to the conchal bowl. A large crescent of conchal cartilage is then removed, taking care not to injure the meatal skin and retain its continuity with the Koerner’s flap. To provide an opening adequate to allow drainage and selfcleansing of the surgical defect, a meatoplasty should accept comfortably the surgeon’s index finger5

Meatoplasty 53 Siebenmann’s Meatoplasty Siebenmann’s meatoplasty is discussed in Figure 12.

Portmann’s Technique of Conchomeatoplasty4 Figures 13 to 23 discuss the Portmann’s technique of conchomeatoplasty.

Fig. 12:  The Siebenmann’s meatoplasty employs a Y-shaped

Fig. 13:  The external auditory meatus of the patient is

incision to split the posterior aspect of the meatal skin cuff extending into the concha

shown before the meatoplasty

Fig. 14:  The incisions are made in

Fig. 15:  The meatotomy incision is being taken

the postaural soft tissues

54 Otology and Lateral Skull Base

Fig. 17:  The lateral flap is thinned using a sharp knife

Fig. 16:  A second incision is taken partly dividing the concha

A

B Figs 18A and B:  The division of the meatus into a superior and inferior lateral meatal flaps is shown

Fig. 19:  The three-flap meatoplasty result in a sufficiently enlarged meatus

Fig. 20:  The superior lateral flap is being sutured

Meatoplasty 55

Fig. 21:  The inferior lateral flap is being sutured

Fig. 23:  The end result is an adequately wide meatoplasty

POINTS TO REMEMBER There are certain salient features that authors would like to highlight, irrespective of the technique used. • A meatoplasty is most definitely one of the important steps in an “open technique” surgery, as a well

Fig. 22:  The anterior flap is being sutured

performed surgery is bound to fail in the presence of a poorly performed meatoplasty. • Performing the meatoplasty either before drilling or after completing the mastoidectomy bears absolutely no consequence on the outcome of the meatoplasty. • Irrespective of whether the cartilage is trimmed or not, one must ensure that no part of the cartilage must lie exposed without skin covering it, since this can result in infection and subsequent stenosis. • An ideal-sized meatoplasty is conventionally described as one which can accommodate the surgeon’s index finger comfortably, but in authors’ experience, it is quite impossible to create too large a meatoplasty and most definitely, it is better to err on the side of creating a so-called too large meatoplasty than creating a small one. • Within 4–6 weeks of surgery, the authors have seen the meatoplasty to shrink by approximately 30% of its diameter on the operation table and hence, what seems too large intraoperatively, eventually becomes almost similar to the size of the normal external auditory meatus! An enlarged meatus is an integral part of the CWD procedure and on failure to perform an adequate meatoplasty, even the most perfectly performed CWD procedure may fail due to inadequate exteriorization.6

56 Otology and Lateral Skull Base

THE SURGICAL TECHNIQUE OF

Gray, Consultant Otorhinolaryngologist at Sheffield (Figs 24 to 26).

The simplest and surest technique to revise a stenotic meatoplasty is by using the conchal flap meatoplasty technique which was first devised in the late 1950s by Mr W Hinds, Consultant Plastic Surgeon and Mr J Duncan

CONCLUSION

Fig. 24: Here, a crescent-shaped superiorly-based full

Fig. 25:  The skin over the posterior wall of the canal and

REVISION MEATOPLASTY

thickness skin flap is elevated along the posterior border of the external auditory canal to 6 o’clock inferiorly. This flap is based at the root of the helix. A second incision is made on the roof of the external auditory canal at 12 o’clock

Fig. 26:  The V-shaped flap is transposed to lie in the roof of the external auditory canal whereas the skin over the concha is sutured to the posterior canal wall skin

Creating an adequate meatoplasty (Fig. 27) is an important and integral part of the open technique surgery since

concha is elevated, to expose the underlying cartilage. This is then trimmed along with the soft tissues so as to create a wide opening

Fig. 27:  A well-healed adequate meatoplasty

Meatoplasty 57 it not only allows ventilation and assists in the “self-cleansing” action of the cavity but also provides an easy access to visualize and clean the mastoid cavity. The key to success in otological surgery is not whose technique one uses, but how well one uses it and one’s own ability and judgment.7

REFERENCES 1. Martin-Hirsch DP, Smelt GJ. Conchal flap meatoplasty. J Laryngol Otol. 1993;107(11):1029-31. 2. De la Cruz A, Linthicum FH, Luxford WM. Congenital atresia of the external auditory canal. Laryngoscope. 1985;95(4):421-7.

3. Sanna M, Russo A, Khrais T, et al. Canalplasty for severe external auditory meatus exostoses. J Laryngol Otol. 2004; 118(8):607-11. 4. Portmann M. “How I do it”—otology and neurotology. A specific issue and its solution. Meatoplasty and conchoplasty in cases of open technique. Laryngoscope. 1983;93 (4):520-2. 5. Paparella MM, Meyerhoff WL. “How I do it”—otology and neurology: a specific issue and its solution. Meatoplasty. Laryngoscope. 1978;88(2 Pt 1):357-9. 6. Fisch U, May J. Mastoidectomy. In: George (Ed). Tympano­ plasty, Mastoidectomy and Stapes Surgery. New York/ Stuttgart: Thieme Publishing Group; 1994. pp. 145-99. 7. Sheehy JL. Cholesteatoma surgery: canal wall down procedures. Ann Otol Rhinol Laryngol. 1988;97(1):30-5.

CHAPTER

7

Intratympanic Injection Vicky S Khattar, Bachi T Hathiram, Supriya Rode, Hemant Sharma

INTRODUCTION Transtympanic chemical perfusion of the inner ear is a safe and inexpensive technique, and can easily be performed by an otologic surgeon. With inner ear perfusion, high inner ear concentrations of medication can be achieved and systemic side effects are minimized.1

INDICATIONS • • • •

Meniere’s disease (MD) and vertigo Sensorineural hearing loss Autoimmune inner ear disease As part of the management of tinnitus.

PREOPERATIVE EVALUATION • Baseline pure tone audiogram is done for all patients. • In case of unilateral sensorineural hearing loss, a magnetic resonance imaging (MRI) of brain is done to rule out any retrocochlear pathology.6-8 • In case of MD, –– Electrocochleography (ECOG) can help in localizing the beneficial ear. –– Electronystagmography (ENG) can be helpful to demonstrate reduced vestibular responses and is essential to establish vestibular function in the nonsurgical ear when a destructive procedure is contemplated.

ANESTHETIC CONSIDERATIONS • Children: General anesthesia • Adults: Local anesthesia by local infiltration with lidocaine 2% with adrenaline (1:200,000) postaurally and endomeatally in the four quadrants at the junction of

the bony and cartilaginous external auditory canals. Topical anesthesia may also be given with 4% xylocaine solution. After the injection, the patient is advised to avoid swallowing for 30 minutes and to lie down with the affected ear up for 30 minutes, to allow for the maximum perfusion of the round window area.

SURGICAL STEPS • Patient is explained the procedure. • Written informed valid consent is taken. • Postaural and four quadrant infiltration with 2% lignocaine in adrenaline (1:200,000) is done. • Ear is examined under microscope using an appropriate size aural speculum (Figs 1 and 2). • External auditory canal is thoroughly cleaned with normal saline irrigation and suction. • A puncture is made in the anteroinferior quadrant of the tympanic membrane using a no. 25 needle (Fig. 3). • The desired medication is infiltrated in the posteroinferior quadrant of the tympanic membrane using no. 25 long needle (Fig. 4). • The initial puncture in the anteroinferior quadrant serves the purpose of allowing air to escape from the middle ear cavity as it is replaced by the medication (Fig. 5). • A medicated gelfoam is kept over the infiltration site. Sterile cotton is kept in the external auditory canal (Fig. 6). • The commonly used medications for intratympanic injections in various trials are as follows: –– Gentamicin2,3 –– Dexamethasone4 –– Dexamethasone and hyaluronic acid5 –– Gentamicin salicylate6 –– Dexamethasone and gentamicin7

Intratympanic Injection 59

Fig. 1: Intraoperative microscopic view of the left ear—a

Fig. 2: Once the tympanic membrane is seen, the

Fig. 3: The anterior puncture being made at the superior

Fig. 4: The medications being delivered through a

Toynbee’s aural speculum has been inserted to visualize the tympanic membrane. Note the light reflex

end of the light reflex. This ensures a “sump” below this puncture, for retaining the injected medications, albeit temporarily. It also extrapolates approximately to the round window niche being “submerged” in the temporarily retained medications, allowing for adequate time for perfusion of the latter through it. More importantly, it allows for the air in the middle ear to escape as the medications are delivered. This is important as the patient is asked to withhold swallowing, thus preventing the middle ear from evacuating its air via the Eustachian tube

microscope is adjusted to a higher magnification

posteroinferior puncture, just lateral to the round window niche

60 Otology and Lateral Skull Base

Fig. 5: The end-point of the injection procedure is when

Fig. 6: A piece of gelfoam dipped in the same injection

DOSAGES

injections. The duration is also variable, but usually the treatment should be completed within 2–3 weeks (commonly) to rarely up to 8–12 weeks.

the medications are seen to fill up the middle ear, as well as a little excess medication is seen seeping out from the posteroinferior puncture

The most commonly used drugs are steroids and gentamicin, and their dosages have been mentioned below: • Gentamicin: Most studies have employed a concentration of 26.7 mg/mL of gentamicin solution. The usual dose administered is between 0.2 mL and 0.6 mL, depending on the middle ear volume, with an average of 0.4 mL. • Dexamethasone: The literature varies as far as the dosages of the drug that have been administered, which range from 4 mg/mL and 5 mg/mL (commonly used) up to 24 mg/mL (maximum concentration of commercially available drug). The volume stays the same at 0.4 mL. • Methylprednisolone: Recently, studies have shown it to be more concentrated in the endolymph after intratympanic administration, and can be given in dosages of 40 mg/mL for a volume of 0.4 mL.

FREQUENCY The frequency also varies as per various studies, and range from twice daily injections, to once every 2 days, to weekly

fluid is kept over the two punctures. This serves to seal the puncture sites till the tympanic membrane heals. Also, keeping a moist gelfoam eliminates any gradient between the middle ear and the gelfoam, and prevents the latter from resorbing the delivered medication out of the middle ear by capillary action. It also eliminates the need to evacuate the excess medications that have spilt into the external auditory canal after the injection

NEWER TECHNIQUES AND MODIFICATION8

The technique mentioned above is a passive drug delivery system. All passive drug delivery systems rely on the specific pharmacokinetic profiles of their preparations, to facilitate the drug delivery to the target organ, i.e. perilymph and endolymph. They are namely: • Biodegradable polymer intratympanic delivery • Hydrogel based intratympanic delivery • Nanoparticle delivery Active drug delivery systems are also now being extensively studied. Their need arose due to their advantages, namely direct delivery to the round window niche, and the possibility of multidose drug delivery (or even continuous drug delivery) and preferably self-administered. Some developments in this field are: • Round window microcatheter • Silverstein MicroWickTM • Preclinical ALZET® Osmotic Pump • Totally implantable drug delivery system

Intratympanic Injection 61

COMPLICATIONS AND THEIR MANAGEMENT

• Short-lasting vertigo: Rest and oral medication if required. Most patients are able to walk around unassisted after 20–30 minutes following an intratympanic injection. Permanent vertigo and imbalance have not been reported. • Otitis media: When otitis media occurs with a ventilation tube in place, the option of use of antibiotic ear drop is recommended. • Tympanic membrane perforation: Steroids impair wound healing and one might expect slower closure. This complication can be managed by surgical closure of the perforation. • Hearing loss: Most physicians using intratympanic steroids feel that there is little risk of hearing loss.9

REFERENCES 1. Hoffmann KK, Silverstein H. Inner ear perfusion: indications and applications. Curr Opin Otolaryngol Head Neck Surg. 2003;11(5):334-9.

2. Yang GS, Song HT, Keithley EM, et al. Intratympanic immunosuppressives for prevention of immune-mediated sensorineural hearing loss. Am J Otol. 2000;21(4):499-504. 3. Derby ML, Sena-Esteves M, Breakefield XO, et al. Gene transfer into the mammalian inner ear using HSV-1 and vaccinia virus vectors. Hear Res. 1999;134(1-2): 1-8. 4. Van de Water TR, Staecker H, Halterman MW, et al. Gene therapy in the inner ear. Mechanisms and clinical implications. Ann N Y Acad Sci. 1999;884:345-60. 5. Van Wijk F, Staecker H, Keithley E, et al. Local perfusion of the tumor necrosis factor alpha blocker infliximab to the inner ear improves autoimmune neurosensory hearing loss. Audiol Neurotol. 2006;11(6):357-65. Epub 2006. 6. Lalwani AK, Jero J, Mhatre AN. Developments in cochlear gene therapy. Adv Otorhinolaryngol. 2002;61:28-33. 7. Raphael Y, Frisancho JC, Roessler BJ. Adenoviral-mediated gene transfer into guinea pig cochlear cells in vivo. Neurosci Lett. 2000;207(2):137-41. 8. Leary Swan EE, Meschler MJ, Sewell WF, et al. Inner ear drug delivery for auditory applications. Adv Drug Deliv Rev. 2008; 60(15):1583-99. 9. Doyle KJ, Bauch C, Battista R, et al. Intratympanic steroid treatment: a review. Otol Neurotol. 2004;25(6): 1034-39.

The Surgical Technique of Otoplasty 62

62 Otology and Lateral Skull Base CHAPTER

8

Surgical Approaches to the Middle Ear Cleft and Their Indications Vicky S Khattar, Bachi T Hathiram

INFILTRATION The first step after the patient is anesthetized, positioned, the part is painted and draped, is the infiltration of the ear with either saline adrenaline (if the surgery is performed under general anesthesia) or 2% lignocaine adrenaline (if the surgery is performed under local anesthesia) (Figs 1 to 10).

BASIC INCISIONS There are three basic incisions used in the surgery for middle ear pathologies: (1) Rosen’s endomeatal incision, (2) Lempert’s endaural incision and (3) Wilde’s postaural incision.

Rosen’s Endomeatal Incision This incision is taken with a flag or side micro ear surgery knife on the posterior bony external auditory canal (EAC). Two vertical incisions running upward from 6 o’clock to 12 o’clock position are taken subperiosteally on the bony

Fig. 2: A small subcutaneous bleb is first created, and it is through this site that further infiltration is carried out. This is especially of use in patients being operated under sedation, since the site of puncture being anesthetized, helps to avoid discomfort to the patient

Fig. 1: The postaural groove where infiltration will commence

Fig. 3: The subcutaneous infiltration is completed in the postauricular groove. Note the obliteration of the groove

Surgical Approaches to the Middle Ear Cleft and Their Indications 63

Fig. 4: The infiltration is then done in the region of the incisura terminalis anteriorly and extended in the subcutaneous tissues of the external auditory canal (EAC)

Fig. 5: The solution is infiltrated subperiosteally in the

Fig. 6: An aural speculum of adequate size is introduced in

Fig. 7: Bone-deep infiltration is now done in the incisura

EAC. These are gently turn toward the 9 o’clock to meet at a point 6–8 mm away from the annulus (Fig. 11).

• Facial nerve needling for hemifacial spasms • Chemical labyrinthectomy

Indications

Lempert’s Endaural Incision

Below mentioned are the indications for Rosen’s endomeatal incision: • Stapedotomy • Ossiculoplasty • Chorda tympani neurectomy • Tympanic neurectomy • Tympanoplasty

The incision is started at the 12 o’clock position (roof ) in the bony EAC and extends from the annulus to about 1–2 cm in front of the tragus. It runs in the incisura terminalis between the tragus and the helix, and thus does not cut through the cartilage of the auricle. A second incision is taken at the 6 o’clock extending from the annulus to a point just short of the junction of bony and cartilaginous

the canal to aid in hydrodissection in the subperiosteal plane

bony external auditory canal (EAC). The bleb created in the posterior wall is seen indicating that the plane of infiltration is subperiosteal. This serves the dual role of hemostasis and hydrodissection

64 Otology and Lateral Skull Base

Fig. 8: Infiltration is carried out in the subperiosteal

Fig. 9: Infiltration is similarly carried out in all quadrants

Fig. 10: Infiltration at the site of harvesting

Fig. 11: Rosen’s endomeatal incision

plane at the bony cartilaginous junction

the temporalis fascia graft

of the bony external auditory canal (EAC)

EAC. A third horizontal incision on the bony EAC joins the two (Figs 12 to 18).

Indications Below mentioned are the indications for Lempert’s endaural incision: • Tympanoplasty • Mastoidectomy • Stapedotomy • Facial nerve decompression • Ossiculoplasty

Wilde’s Postaural Incision This incision extends from the superior end of the pinna to the mastoid tip about 0.5 mm behind the postaural groove (Fig. 19).

Fig. 12: Marking out the endaural incision

Surgical Approaches to the Middle Ear Cleft and Their Indications 65

Fig. 13: The superficial segment of the endaural incision

Fig. 14: The endaural incision is deepened

Fig. 15: The incision being taken at the 6 o’clock position

Fig. 16: The horizontal incision taken just short of the bony cartilaginous junction to join the two vertical incisions

Fig. 17: The flap being elevated

Fig. 18: Elevation of the flap and the

is taken, using the endaural retractor to ensure that the cartilage is not cut mistakenly

in the 12 o’clock position

annulus to enter the middle ear

66 Otology and Lateral Skull Base Indications

Below mentioned are the indications for Wilde’s postaural incision: • Tympanoplasty • Mastoidectomy • Ossiculoplasty • Revision ear surgery for cholesteatoma or unsafe chronic suppurative otitis media • Facial nerve decompression • Endolymphatic sac decompression The postaural Wilde’s incision has been extended and/or modified for other surgeries through the mastoid, such as for cochlear implantation, surgery for boneanchored hearing aid (BAHA), surgery for glomus tumors, surgery for acoustic neuroma removal, surgery for tumors of the temporal bone, etc. These specific modifications have been described in the relevant chapters, and hence, are not discussed here.

ACKNOWLEDGMENTS Fig. 19: Diagrammatic representation of the postauricular incision

Authors are thankful to the Dean, TN Medical College and BYL Nair Charitable Hospital for granting permission to publish this chapter.

CHAPTER

9

Tympanoplasty (Author’s Technique) Shabbir Indorewala

INTRODUCTION Basic philosophy: The three basic principles on which this technique is based are: (1) the graft should overlap the remnant tympanic membrane by a minimum of 4 mm, (2) the graft should be well adapted in its new destination and (3) the fascia lata grafts are known to shrink less during first 5 days of healing. Graft overlap: It is essential that the graft overlap the remnant tympanic membrane by at least 4 mm on all sides. This length of overlap is called lap length. Graft adaptation: A perfectly adapted graft is the hallmark of the success of the closure of a perforation of the tympanic membrane. A well-adapted graft has four components in it. They are: (1) the graft should completely cover the perforation; (2) it should have the lap length of 4–6 mm all around. If the distance between the margin of perforation and annulus is less than 4 mm, then the graft must turn up on the canal wall so as to achieve a minimum 4 mm of lap length. This should of course happen without dog-ear formation; (3) it should be in a single layer rather than folded on itself at any place and (4) there should be no excess of graft tissue. It is not good to just shove in a fascia in the middle ear which is all folded on itself and blocks the middle ear and the Eustachian tube. A well-adapted graft will neither block the middle ear nor block the Eustachian tube. Graft shrinkage: Free fascia grafts are known to shrink twice. The immediate shrinkage occurs soon after the fascia is harvested. We as surgeons know that the harvested fascia looks smaller than the defect created by the harvest of the fascia. The grafts are also known to shrink after its placement under the remnant tympanic membrane, in first 5 days of healing before graft integration occurs. This is delayed graft shrinkage. If the graft shrinks and becomes smaller than the perforation size, a remnant perforation will occur.

It is established by animal experiments and human observations that the temporal fascia grafts shrink more and also most unpredictably when compared to shrinkage of the fascia lata grafts. If a 70 mm2 perforation is closed by a 100 mm2 temporal fascia graft, and if the temporal fascia shrinks to become 65 mm2, a 5 mm2 remnant perforation will occur. On the other hand, if the 70 mm2 perforation is closed with 100 mm2 fascia lata, after 5 days, the fascia lata may shrink and become 80 mm2. No remnant perforation will occur.

INDICATIONS FOR THE SURGERY Chronic simple perforation of the tympanic membrane must be closed. Chronic simple perforation of the tympanic membrane leads to recurrent middle ear infection, hearing loss and leads to ossicular damage over a period. To avoid all this, it is best closed at the earliest given opportunity.

PREOPERATIVE EVALUATION The aims of the preoperative evaluations are essentially directed to know the status and the functional integrity of ear and to look for any general conditions that are contradictory to the surgery. They include: • Ear microscopy: This allows the surgeon to make accurate diagnosis. It allows ruling out unexpected hidden cholesteatoma, tympanosclerosis, granular myringitis, herodion, retraction pockets, adhesive process, etc. It is essential to know all these conditions before the surgery can be finalized. If the canal and the middle ear is filled with debris and discharge, suction toilet under microscope helps in making the ear free of active infection and free of pollution by multitude of debris like pus, scabs, foreign bodies, forgotten cotton plugs, etc. Pedunculated polyps, granulations can also be removed from the ear with suction under microscope. This helps in making the ear dry in just 5–7 days.

68 Otology and Lateral Skull Base • Audiological evaluations: It gives a good indication of the hearing status of the ear under consideration. It allows knowing the cochlear reserve, the middle ear component in the hearing loss, and also establishes the auditory status of the other ear. Auditory status of the other ear becomes very critical, if the ear under consideration is the only hearing ear. It cannot be stressed more that audiological evaluations has a great medicolegal importance. • Routine laboratory test run: Routine tests like complete blood count, routine urine, blood sugar, blood urea, HIV and hepatitis B surface antigen (HBsAg) immunity status are all essential to rule out any hidden medical conditions that will contradict surgery. • Physical fitness: Let a physician have a look at the patient, get blood pressure recorded and perform ECG, if needed echocardiography or any other tests that the physician may suggest making the surgery event free. • Confirm that the patient is not on any antiplatelet or other similar medicines prior to taking him up for surgery.

ANESTHETIC CONSIDERATIONS If the patient is adult and emotionally stable, local anesthesia using freshly prepared solution of 1% lignocaine with adrenaline (1/2 cc of 1:1,000 adrenaline in 30 cc vial of lignocaine) is best. The surgeons do not like to sedate the patient. This helps in getting full cooperation of the patient during the surgery. A sedated patient may not cooperate fully. A little explanation to the patient about what he may experience during surgery helps in settling down his anxiety a lot, making him an active participant in the surgery, rather than a cause of concern to the operating team!

A

Method of Local Infiltration A freshly prepared solution of lignocaine-adrenaline as described above is taken in 2 cc (autoclaved glass) syringe. Use a 20 FG needle to aspirate from a 30 cc vial of the lignocaine. The surgeons use a 26 FG 1.5 inch (0.45 mm ´ 38 mm) long needle to infiltrate. Under microscope the surgeons inject just (1 mm) lateral to the junction line of thick (mobile and hairy) and thin (non-mobile and nonhairy) canal skin. The volume of injection is determined by watching for the blanching of the deep canal. This blanching should be observed till it reaches the annulus. The speed and the volume of injection should be such that no blebs form in the canal. Thus, while injecting, one should keep focused on deep canal for blanching to reach up to the annulus and no blebs form. It is for this reason that the surgeons prefer a 2 cc (autoclaved glass) syringe. 26 FG (0.45 mm) needle gives least pain of prick and 1.5 inch (38 mm) length of needle allows deep injection without the hand or syringe coming in the way of visual axis. The injection is made in the anterosuperior, anteroinferior, posterioinferior and posteriosuperior regions of the canal. A total of about 1.5 cc is generally enough for this. It is to be noted that promontory mucosa, if not edematous, gets easily anesthetized with surface anesthesia. Just 0.5 cc of lignocaine-adrenaline solution used as ear drops in the (middle) ear is enough. If, however, the promontory mucosa is edematous, then this mucosa will not get anesthetized with surface anesthesia. A submucosal injection is to be made under the promontory mucosa with a needle whose tip is bent as shown in Figures 1A and B. Fortunately it is easy to inject under an edematous mucosa. A separate local infiltration is made at the donor site for fascia lata. Using the same solution and syringe and needle about 6 cc of lignocaine-adrenaline is enough.

B Figs 1A and B: (A and B) Submucosal injection on edematous promontory mucosa with a bent needle

Tympanoplasty (Author's Technique) 69 However, if the patient needs general anesthesia, either for anxiety, emotional instability, age factor or any other reason, then for general anesthesia author’s anesthesiology department prefers to use of propofol, isoflurane and dexmedetomidine. Even if the patient is under general anesthesia, surgeons still prefer infiltration with freshly prepared solution of lignocaine-adrenaline. It has two advantages: (1) it gives good hemostasis and (2) it reduces the drug need of general anesthesia. It is important to have a gap of 15 minutes after lignocaine-adrenaline infiltration and before taking the incision for the full effect of anesthesia and hemostasis to set in.

will be difficult to make as it will be made in a thick skin. Also the flap will have a thick skin to be raised thus further narrowing the canal. A medially placed incision will make the tympanomeatal flap very small. Similarly, a spiraling incision is not preferred.

Raising the Posterior Tympanomeatal Flap With a combination of horizontal, sickle and vertical knife, the tympanomeatal flap is raised off the bony posterior canal. Care should be taken that this flap does not tear (Fig. 4). If the flap is raised utilizing the entire length of the incision (instead of making a tunnel), this can be achieved with certainty and quickly. Expose the whole length of

STEPS OF SURGERY Dry and Clean the Ear After painting and draping, it is essential that convolutions of the pinna and the surrounding exposed skin are cleaned with dry gauze. The canal should be washed with saline and cleaned with suction toilet. It is essential that all the related areas are clean and dry. Figure 2 shows diagrammatic view of normal ear showing different parts as a reference to other diagram.

The Posterior Incision An incision is made with a horizontal knife on the posterior canal wall just medial to the junction line of thick and thin skin. The incision is parallel to the annulus and for the right ear it is from 11 to 7 o’clock interval (Figs 3A and B). An incision lateral to the junction line

A

Fig. 2: Diagrammatic view of normal ear showing different parts as a reference to other diagrams

B

Figs 3A and B: (A) Surgical and (B) diagrammatic view of permeatal posterior incision. Incision for posterior tympanotomy is made just medial to the junction of the hairy and non-hairy canal skin (Yellow arrow: Hairy canal skin; Black arrow: Non-hairy canal skin; White arrow: Incision)

70 Otology and Lateral Skull Base annulus before attempting to lift it off the sulcus. The annulus is best lifted off the sulcus near its inferior exposed end to avoid inadvertent damage to the chorda. Lift the entire length of the exposed annulus. Lift the inferior annulus also and go as far forward as is possible. Depending on the angulation of the canal and the tympanic membrane, it is sometimes possible to lift the annulus up to 5 o’clock position. Superiorly lift the annulus up to the malleus neck. Sometimes the middle ear mucosa is very thick and needs to be specifically cut to achieve completion of posterior (permeatal) tympanotomy (Figs 5A and B).

Inspection of the Middle Ear Inspect the middle ear carefully; look for hidden retraction pockets, forgotten foreign bodies, tympanosclerosis, status of ossicular chain, status of middle ear mucosa, etc. Further action will depend on findings of each element just described.

Strip the Malleus Once the posterior (permeatal) tympanotomy is fully accomplished, the malleus handle is exposed in its entire length. Make an incision in the mucoperiosteum on the posterior surface of the malleus with a sickle knife and lift the mucoperiosteum off the malleus on all 360° so that the malleus and the tympanic membrane are completely separated (Fig. 6).

The Anterior Incision It is now time to make an incision on the anterior canal wall. The anterior incision is midway between the annulus and the junction line of the thick-thin skin. For the right ear, it is from 1 to 5 o’clock interval. The incision is parallel to the annulus (Figs 7A and B). The posterior and the anterior incisions are thus at different levels. This prevents the two incisions to become continuous in case either of the two incisions is extended on any side either accidentally or by design.

Raising the Anterior Tympanomeatal Flap Fig. 4: Posterior tympanomeatel flap raised up to the annulus (arrow)

A

The anterior tympanomeatal flap is also raised in the same way as the posterior tympanomeatal flap. The anterior

B Figs 5A and B: (A) Surgical and (B) diagrammatic view of completed posterior tympanotomy (Black arrow: Malleus handle; Yellow arrow: Incudostapedial joint)

Tympanoplasty (Author's Technique) 71 annulus is lifted out of the anterior sulcus in its entire length. This is called the anterior tympanotomy (since the anterior annulus is lifted out of the anterior sulcus) (Figs 8A and B). In the process, the annulus is lifted out of the sulcus in entire length (and around all 360°).

Harvest of the Fascia Lata The lateral surface of the (generally ipsilateral) thigh is already kept prepared by painting with antiseptic solutions and draped with sterile drapes. Local infiltration is already made at the time of initial preparation. 10 cm above knee joint on lateral surface of the thigh, the incision

is marked (Fig. 9). An incision of about 6 mm is enough. The incision should be long enough for a no. 15 blade to go in and allow a small window for visualization. All subcutaneous fat is excised. Depending upon the obesity, sometimes chunks of fat may need removal. Sometimes the surgeons use a large ear specula inserted in the skin incision to retract fat and allow direct visualization of the fascia. Once enough of fascia is exposed four cuts are made in the fascia so as to harvest an approximately 18 mm (anteroposteriorly) by 26 mm (superoinferiorly) of the fascia. The donor site does not bleed much. There are no important structures in this region that need specific protection. The wound is closed with a single stitch.

Preparation of a Graft

Fig. 6: Malleus handle stripped of mucosa and disconnected form the remaining tympanic membrane

A

The surgeons do not allow the fascia to dry at all. Once the fascia is harvested, it is placed in the saline bowl. To craft the harvested fascia into a graft to be used in the middle ear, first remove all the fat and loose connective tissues from both surfaces of the fascia. It is much easy to clear the muscular surface of the fascia than the cutaneous surface. The cutaneous surface need not be made absolutely bare, as the loose connective tissues contain blood vessels, which play important role in early uptake of the graft. Cut the fascia into 24 mm length by 16 mm breadth (Fig. 10). Cut all the four corners by 8 mm in length and 4 mm in breadth. This will make fascia look like a+ and will give four tails to the central square portion of the fascia (Fig. 11). Make a 3 mm slit in the center at the base of the superior tail for accommodation of the malleus handle (Fig. 12). This completes the conversion of the fascia into a graft. The graft is now ready for its final placement.

B

Figs 7A and B: (A) Surgical and (B) diagrammatic view of permeatal anterior incision. Incision for anterior tympanotomy (white arrow) is made midway between the annulus (black arrow) and the junction line (yellow arrow) of the hairy and nonhairy canal skin

72 Otology and Lateral Skull Base

A

B

Figs 8A and B: (A) Surgical and (B) diagrammatic view of anterior tympanotomy completed; anterior tympanomeatal flap reflected posteriorly (Black arrow: Malleus lateral process seen through the anterior tympanotomy; Yellow arrow: Protympanum)

Fig. 9:  Incision (yellow arrow) marked along the skin crease

Fig. 10: A 10 mm × 24 mm fascia lata just

on the lateral aspect of thigh 10 cms above the knee joint (black arrow)

before trimming the corners

Placement of the Graft in the Middle Ear Flush the middle ear with saline and suck away all the blood and saline. A bloodless field makes the placement of the graft very easy. Place the graft on the specula and open the posterior tympanotomy wide. Slide the graft into the posterior tympanotomy, till the slit made for the malleus is near the umbo. Fish the malleus handle through the slit and pull the graft superiorly till the superior lip of the slit is beyond the lateral process of malleus (Fig. 13). The lateral process of the malleus acts as a hook and does not allow the graft to slip down again, thus greatly stabilizing

the graft. It is now time to spread the superior tail of the superior canal wall, posterior tail on posterior canal wall and the inferior tail on the inferior canal wall. Put the posterior tympanomeatal flap back in place and open the anterior tympanotomy wide. Pull the anterior tail on the anterior canal wall. Adjust the anterior ends of superior and inferior canal walls. Put the anterior tympanomeatal flap back in place. At this time all the four tails are respectively on all four canal walls. As the corners of the graft are cut, there will be no dog-ear formations. The graft will be well beyond the margins of perforation by at least 4 mm, there will be no folding of graft due to excess length, and

Tympanoplasty (Author's Technique) 73

Fig. 11: The four corners of the fascia are cut (each 4 mm × 8 mm). The fascia now has central piece and four tails. Cutting corners facilitate the final adaptation of the graft under the tympanic membrane and the tails turn on the canal walls. The dog-ear formation is avoided as the corners are removed

Fig. 12: A slit is made at the base of the superior tail for malleus handle fishing

Canal Packing The canal is packed with gelfoam, taking care that the meatal flaps and the graft placement is not disturbed. Put a gauze piece and cotton and a sticking tape to prevent the cotton falling off the scaphoid fossa.

POSTOPERATIVE EVALUATION Since only lignocaine is used as anesthetic agent, the patient is fully conscious and can be shifted out of OT on a trolley.

MODIFICATIONS SUGGESTED

Fig. 13: Malleus handle completely fished out of the slit in a fascia lata graft. Hooking the graft over the lateral process prevents the graft from sliping off the malleus during adaptation maneuver

the graft will be medial to remnant tympanic membrane and medial to malleus and handle yet will extent of the superior canal wall. With a small piece of gelfoam held in the forceps, dab over the tympanomeatal flaps to even out all the wrinkles. Invariably at this time a good cone of light reflex is seen in the anteroinferior quadrant of the graft. At this point the graft is well adapted in its new destinations (Figs 14A and B).

The above procedure is described for a subtotal tympanic membrane perforation. If the perforation is limited posterior to malleus, then it is not necessary to do anterior tympanotomy, as enough of lap length will be available from an intact anterior tympanic membrane. Similarly, if the perforation is only anterior to the malleus, then the posterior (permeatal) tympanotomy may not be performed. Only anterior tympanotomy will suffice. The posterior half of the remnant tympanic membrane will provide enough of lap length to the graft.

COMPLICATIONS Sometimes, the donor site muscle herniation occurs. This is a harmless condition and needs no treatment. The herniation resolves in 6–12 months. Remnant perforation rate with this technique is 1% for large and subtotal perforations. About 1% patients have

74 Otology and Lateral Skull Base

B

A

Figs 14A and B: (A) Surgical and (B) diagrammatic view of completed permeatal tympanoplasty. Graft placed in inlay position with good lap length and well adapted (White arrow: Showing light reflex; Black arrow: Malleus handle)

granular myringitis which does not settle. Thus about 2% cases need revision surgery. The surgeons have not seen a single case of anterior tympanomeatal angle blunting in a series of 6,000 cases. Remnant perforations occur in two situations: (1) in cases of graft lysis and (2) in cases of graft edema. It is not known what brings about the lysis or the edema of the grafts. May be the two pathologies are different ends of the same spectrum. Once either graft becomes edematous or gets lysed, there is very little that can be done, except a revision surgery after the acute phase of the pathology is over. Complications, like facial nerve and inner ear dysfunctions, are known but are fortunately rare. They are mentioned here only to complete the list.

SPECIAL INSTRUMENTS USED FOR THE SURGERY

No special instruments are required for this type of surgery. However, the surgeons use a “graft stencil” (Fig. 15) to craft the fascia into the graft so as to save on time and cut the fascia accurately.

ADVANTAGES OF AUTHOR’S TYMPANOPLASTY

It has following distinct advantages: • It gives good success rate of perforation closure for large, subtotal and total perforations. About 98% of ears have complete closure of perforation at a follow-up period of minimum 1 year.

Fig. 15: Stencil used to cut the fascia into a four tail graft

• It can be performed in about 30–40 minutes and with great ease for the surgeon and the patient. • The patient has no incision, stitch or scar around the ear. • The patient has minimal morbidity in terms of pain and soreness around the ear. The donor area is sore at the most for 2 days. • At the end of 1 month, the ear is all healed. After 12 months, it is not possible to know even if the eardrum was perforated and has been repaired. The light reflex is in anteroinferior quadrant and conical in shape. The texture of the neomembrane looks almost like that of the natural tympanic membrane.

CHAPTER

10

Ossiculoplasty Amith I Naragund, RS Mudhol

INTRODUCTION

AUSTIN’S CLASSIFICATION OF

Ossicular chain destruction or erosion is a common complication of chronic suppurative otitis media. A moderate conductive deficit in excess of 40 decibels (dB) indicates ossicular discontinuity, usually from erosion of the long process of the incus or the stapes superstructure.1 Hall and Rytzner (1957) performed the first ossicular chain reconstruction by repositioning the patients’ own incus after accidentally fracturing the stapes superstructure during stapes mobilization surgery for otosclerosis.2 Since then, many innovative designs and materials have been used to bridge the ossicular chain defects. Ossicular reconstruction can be done as a single stage procedure at the time of middle ear surgery for chronic otitis media but in cases of extensive middle ear disease where the risk of residual or recurrent disease is more, then ossicular reconstruction is staged after 6–12 months.3 Although numerous approaches to ossicular reconstruction have been shown to be successful, no single technique has received universal acceptance. This topic focuses on the various materials used for ossiculoplasty with emphasis on autologous incus interposition ossiculoplasty, surgical technique and its outcomes.

OSSICULAR CHAIN DEFECTS

In the absence of an intact incus, Austin (1971) defined four groups (Table 1). The present techniques of ossiculoplasty are based on the above classified type of ossicular chain defects. Percentage of occurrence of each type of ossicular defect is shown in Figure 1.

Fig. 1: Percentage of occurrence of each type of ossicular defect

Table 1: Austin’s classification of ossicular chain defects Types

Percentage occurrence*

Ossicular status Malleus handle

Incus

Stapes superstructure +

Type A

60

+

–

Type B

23

+

–

–

Type C

8

–

–

+

Type D

8

–

–

–

*Isolated loss of malleus handle (2%) and isolated loss of stapes superstructure (1.7%) were not included in classification because of their rarity

76 Otology and Lateral Skull Base

PATIENT SELECTION (INDICATIONS) FOR OSSICULOPLASTY

• Any patient with chronic otitis media with clinical, audiological or radiological evidence of ossicular chain erosion. • Hearing loss resulting from ossicular problems associated with trauma, adhesive otitis media and congenital ear malformations. • As a second stage procedure following surgery for extensive cholesteatoma which is done after 6 of 12 months from the primary surgery. • Patients with mixed hearing loss, actively discharging ear and children less than 7 years of age (immature Eustachian tube function) are poor candidates for ossiculoplasty.

PREOPERATIVE EVALUATION • A complete history and thorough ear, nose and throat examination should be performed in all patients. The otoscopic examination is best accomplished with the operating microscope. • Audiological evaluation should be done by pure tone audiometry which should include air and bone conduction thresholds with masking as well as speech discrimination scores. All hearing should be confirmed by tuning fork tests. • Tympanometry may be done to differentiate between ossicular fixation and discontinuity and also to know the Eustachian tube function. Acoustic reflex testing is helpful in distinguishing hearing losses resulting from otosclerosis versus an inner ear hearing loss associated with superior semicircular canal dehiscence wherein the reflex is present. • Thin sections of computed tomography (CT) scan of temporal bones may be helpful, particularly in cases with cholesteatoma, in determining the ossicular status, degree of mastoid pneumatization, possible intracranial involvement, labyrinthine fistula and fallopian canal dehiscence.

ANESTHESIA Local anesthesia with 2% xylocaine with 1 in 100,000 adrenaline infiltration is preferred as the patient will be conscious which will help in intraoperative assessment of hearing, facial nerve monitoring and assessment of footplate or labyrinthine fistula. Local anesthetic is infiltrated at four quadrants of the canal all at bony cartilaginous junction, the incisura terminalis and behind the auricle over the mastoid process and periosteum along the

anterior surface of the mastoid process.4 General anesthesia is particularly helpful for children and excessively apprehensive patients.

GRAFT MATERIALS USED FOR OSSICULOPLASTY

Over the years various graft materials have been used to bridge gap between ossicles but till date there is no ideal graft material which is accepted worldwide. Three general classes of prosthesis are used today: (1) autograft, (2) homograft and (3) alloplastic prosthesis.5

Autografts Autografts include ossicles (incus, malleus), cartilages (septal, tragal) and cortical bone. Autologous incus is always better tolerated as it is more physiological and biocompatible thereby giving better hearing results and reduced graft extrusion rate. But this technique requires time and skill to ensure appropriate sculpting in order to minimize ankylosis of the Fallopian canal, scutum and posterior canal wall.6 Advantages and disadvantages of using autografts are given in Table 2.

Homografts Homograft ossicles and cartilage were widely used earlier but their use is now limited because of risk of transmitting infectious diseases such as HIV, prion disease, etc. and also concern related to their preparation and storage.

Alloplastic Prosthesis Alloplastic prostheses are readily available, presculpted and made of synthetic materials like hydroxyapatite, plastipore, titanium, glass ceramics, etc. designed to be biocompatible. These are available as partial ossicular replacement prosthesis (PORP) which can be used in Austin A type of ossicular defects and total ossicular replacement prosthesis (TORP) which is used in Austin B type of ossicular defects. The usual length of PORP is 2.0–4.5 mm and that of TORP is 4.0–7.0 mm. Titanium prosthesis (Figs 2A and B) is an excellent material for ossicular reconstruction because of its high Table 2: Advantages and disadvantages of using autografts Advantages

Disadvantages

Very low extrusion rate

Displacement

No risk of transmitting disease

Complete absorption

Biocompatibility

Small remnant size

No necessity for reconstitution

Possibility of harboring microscopic disease

Ossiculoplasty 77

A

B Figs 2A and B: Alloplastic prosthesis. (A) Titanium

Fig. 3: Canal wall incision for tympanomeatal flap

biocompatibility, biostability and low ferromagneticity. In addition, titanium is lightweight and rigid, making it a good sound conductor.7 Ossicular necrosis, extrusion, displacement and unsatisfactory hearing restoration have been encountered with virtually every type and design. Extrusion of the prosthesis has been reported as high as 39% but can be significantly reduced by placing cartilage or bone between the tympanic membrane and the prosthesis.8

technique, the exposure is more limited, but two-point fixation is maintained. This facilitates slight tension on the prosthesis with respect to the tympanic membrane. Particular care should be taken with dissection in the area of the facial ridge, where the vertical segment of the facial nerve may not be protected by a bony coverage.9

PORP; (B) Titanium TORP

SURGICAL STEPS OF INCUS

INTERPOSITION OSSICULOPLASTY

Approach In case of ossicular chain reconstruction without a concomitant mastoidectomy, the procedure usually is performed with a transcanal approach. If the canal is quite narrow, an endaural or postauricular approach can be employed.

Posterior Canal Wall Incision and Tympanomeatal Flap Elevation Vertical incisions are made at 6 o’clock and 12 o’clock positions, beginning 1 mm lateral to the annulus, and connected by a horizontal incision 10–12 mm lateral to the annulus (Fig. 3). In canal wall down mastoidectomies, the incision is altered. The 6 o’clock position is shifted anteriorly to 4 o’clock and the incision at the 12 o’clock position is avoided altogether. The horizontal incision begins anteriorly and extends toward the mastoid cavity. Using this

Clearance of Middle Ear Disease Once the tympanomeatal flap is elevated, the middle ear disease is completely cleared. Specially in performing a second look procedure, it is essential to check carefully for any residual or recurrent cholesteatoma before considering ossicular chain reconstruction.

Refashioning the Incus Detachment of Incus The incus with necrosed lenticular/long process is detached from the incudomalleal joint and taken out. It is then held with Derlacki’s ossicle holding forceps such that the body of incus is available for drilling and reshaping.

Drilling the Incus Drilling of incus is performed using 0.6 mm diamond burr. The remnant long process is drilled to make it cylindrical in shape with a flat base.10 A socket is drilled in under surface of remodelled long process for engaging the head of stapes (Fig. 4A). Part of short process is removed and a notch is drilled on superior surface of body to accommodate the handle of malleus (Fig. 4B).

78 Otology and Lateral Skull Base

A

B

Figs 4A and B: (A) Socket is drilled with 0.6 mm diamond burr on the remnant of the long process of incus for engaging stapes head; (B) Notch is made with 0.6 mm diamond burr over the body of incus to fit the handle of malleus

A

B Figs 5A and B: (A) Notched incus with short process; (B) Notched incus with long process (M: Malleus handle; I: Refashioned incus; S: Stapes head; F: Stapes footplate)

Repositioning the Incus The mobility of the footplate is first confirmed by applying intermittent pressure over the stapes superstructure and looking for round window reflex. The refashioned incus is then interposed between the handle of malleus and stapes superstructure [(notched incus with short process) (Fig. 5A)]. In cases where stapes superstructure is absent, then incus graft is placed between handle of malleus and stapes footplate [(notched incus with long process) (Fig. 5B)]. A small piece of temporalis fascia or fat pad is first placed over the footplate before placing the refashioned incus between the malleus handle and stapes footplate. This acts as a support to the interposed incus and

prevents dislocation of footplate and seals any eventual perilymph leak.

Alloplastic Prosthesis Alternatively, PORP can be placed between handle of malleus and stapes superstructure (Fig. 6A) in cases where incus is eroded and stapes superstructure and malleus are present. In cases where stapes superstructure is absent, the footplate is first covered by a small piece of temporalis fascia or fat followed by placement of TORP between handle of malleus and stapes footplate (Fig. 6B). This is done to prevent direct contact of the prosthesis with the footplate as sometimes the weight and direct pressure of the prosthesis may cause necrosis of footplate resulting

Ossiculoplasty 79

A

B

Figs 6A and B: (A) Titanium PORP placed between stapes head (S) and handle of malleus (M); (B) Titanium TORP placed between stapes footplate (F) and malleus handle (M)

in perilymph leak and even dead ear at times. The length of the prosthesis required to bridge the ossicular defect is measured by a osseous sizer and any extra length is trimmed by osseous cutter. A piece of conchal cartilage is placed over the prosthesis to prevent its extrusion and resultant residual perforation. This is followed by temporalis fascia grafting over the cartilage.

Outcome Measures Hearing improvement and graft take up rates are the most important outcome measures evaluated after 3, 6, 12 and 24 months postoperatively. Audiometric evaluation includes postoperative air-bone gap (ABG), postoperative air-conduction (AC) threshold and postoperative boneconduction (BC) threshold (0.5, 1, 2, 4 kHz). Postoperative ABG of 20 dB or less is considered a successful hearing result. Anatomical results, that is, closure of tympanic membrane perforation and graft take up are analyzed otomicroscopically.

COMPLICATIONS The complication rates are variable and depend on the surgical technique and the material used for ossicular reconstruction. Complications are more with use of synthetic prosthesis than with auto-incus interposition which is well tolerated as it is more physiological and biocompatible.11

• The most common complication after ossiculoplasty is graft or prosthesis extrusion with a resultant residual perforation and conductive hearing loss. The extrusion rate is much higher with prosthesis as compared to autologous grafts.11 • Sensorineural hearing loss or dead ear has been reported due to fracture and displacement of footplate in cases of malleus footplate assembly. • Facial nerve paralysis can occur in cases of total ossicular prosthesis impinging on dehiscent tympanic segment of facial nerve near the second genu. • Recurrence of disease may affect long-term hearing results in chronic suppurative otitis media.12

SPECIAL INSTRUMENTS USED FOR THE SURGERY (FIGS 7A TO D)

• 0.6 mm diamond burr: This is used to sculpt the incus and create a socket for the stapes superstructure and groove for the handle of malleus during incus interposition ossiculoplasty. • Derlacki ossicle holding forceps: It is used to hold the incus firmly during refashioning of incus for incus interposition ossiculoplasty. • Osseous sizer: It is used to measure the distance between two points in TORP and PORP. • Osseous cutter: It is used to trim the prosthesis as per required length measured using osseous sizer.

80 Otology and Lateral Skull Base

A

B

C

D

Figs 7A to D: Special instruments used for the surgery. (A) 0.6 mm diamond tip burr; (B) Ossicle holder; (C) Osseous sizer; (D) Osseous cutter

REFERENCES 1. Sismanis A. Tympanoplasty. Glasscock-Shambaugh Surgery of the Ear, 5th edition. Elsevier; 2002. pp. 463-85. 2. Frootko NJ. Reconstruction of the middle ear. Scott Brown’s Otolaryngology, 6th edition. United Kingdom: ButterworthHeinemann; 1997. pp. 11/1-11/30.

3. Austin DF. Ossicular reconstruction. Otolaryngol Clin North Am. 1972;5:145-60. 4. Jackson CG. Principles of temporal bone and skull base surgery. Glasscock-Shambaugh Surgery of the Ear, 5th edition. Elsevier; 2002. pp. 264-5. 5. O’Reilly RC, Cass SP, Hirsch BE, et al. Ossiculoplasty using incus interposition: hearing results and analysis of the middle ear risk index. Otol Neurotol. 2005;26:853-8. 6. Kartush JM. Ossicular chain reconstruction. Capitulum to malleus. Otolaryngol Clin North Am. 1994;27:689-715. 7. Martin AD, Harner SG. Ossicular reconstruction with titanium prosthesis. Laryngoscope. 2004;114:61-4. 8. Smyth GD. Five-year report on partial ossicular replacement prostheses and total ossicular replacement prostheses. Otolaryngol Head Neck Surg. 1982;90:343-6. 9. McElveen JT, Cunningham CD, Sheehy JL. Ossicular Reconstruction. Brackman’s Otologic Surgery, 3rd edition. Saunders Elsevier; pp. 161-71. 10. Mahadeviah A. Ossiculoplasty. Surgical Techniques in Chronic Otitis Media and Otosclerosis Text and Atlas, 1st edition. New Delhi: CBS Publishers; pp. 92-111. 11. Naragund AI, Mudhol RS, Harugop AS, et al. Ossiculoplasty with autologous incus versus titanium prosthesis: a comparison of anatomical and functional results. Indian J Otol. 2011;17(2):75-9. 12. Monsell EM. Results and outcomes in ossiculoplasty. Otolaryngol Clin North Am. 1994;27:835-40.

The SurgicalThe Technique of Otoplasty 81 Vibrant Soundbridge CHAPTER

11

The Vibrant Soundbridge Ashutosh G Pusalkar

INTRODUCTION

Vibrating Ossicular Prosthesis Template

The vibrant soundbridge (VSB) is an active middle ear implant for persons with sensorineural, conductive or mixed hearing losses (Fig. 1). The VSB consists of an external part, the audio processor (AP) and an implanted part, the vibrating ossicular prosthesis (VORP). The AP is worn on the head and contains a microphone, a digital signal processor and a battery. The VORP consists of a receiver/ stimulator, a conductor link and a transducer. Information from the AP is sent to the VORP so that the transducer (FMT) vibrates in a controlled manner; specific to each patient’s hearing needs (Fig. 2). The FMT is 2.3 mm in length, 1.8 mm in diameter and weighs about 25 mg. The conductor link has a diameter of 0.6 mm. The surgery performed is called vibroplasty. Vibroplasty is the treatment of hearing loss by a vibratory stimulation of the ossicular chain in the middle ear. When the FMT is in proximity to a vibratory structure of the middle ear, it vibrates the structure and stimulates the auditory system. Selection of the patient for implantation requires the surgeon and the audiologist to work together. A detailed audiological and medical evaluation is performed and reviewed. Before surgery, patients are counselled about the risks and benefits of VSB implantation. Success is optimal, when the patient is well-selected and has realistic expectations.

The VORP template (Fig. 3), made of silicone elastomer, has three functions. The first is to determine optimum implant placement on the mastoid before incising the skin. An outline may be drawn to mark this site. The second is to outline the exact size of the placement before drilling. The third is to verify the size of the placement before placing and suturing the VORP to the skull.

Crimping Forceps The forming forceps, made of stainless steel, is used to crimp the FMT clip around the incus. Other otologic forceps (such as stapes wire crimpers or piston closing forceps) can also be used to form the FMT attachment.

HISTORICAL REVIEW The vibrant soundbridge was invented by Geoff Ball, who was a bilateral soundbridge user. The other landmarks in the history of this device are: • 1996: First patient implanted by U Fisch • 1998: CE-mark (Europe) • 2000: FDA approval (USA) • 2003: Foundation of vibrant MED-EL hearing technology.

Fig. 1: Parts of the vibrant soundbridge

82 Otology and Lateral Skull Base

Fig. 2: The floating mass transducer with its

Fig. 3: The VORP template

attachment clips

A

B Figs 4A and B: (A and B) The floating mass transducer

THE DEVICE It consists of two parts: • The audio processor or AP • The vibrating ossicular prosthesis or VORP, with its active part known as the floating mass transducer (FMT) (Figs 4 and 5).

The FMT is an electromagnetic transducer. It works on the principle of electromagnetic induction. It requires only one point of fixation (the ossicles or the round window). The FMT reproduces and augments the natural movement of the ossicular chain. The FMT is attached to the long process of incus with a titanium clip. It should be in close contact with and parallel to the stapes.

The Vibrant Soundbridge 83

COMPARISON WITH A HEARING AID

Unlike the hearing aid that provides only an “acoustic amplification”, the vibrant soundbridge provides a “direct drive” for the sound waves (Figs 6A and B), which have the following advantages: • Elimination of the occlusion effect • Improved sound quality of own voice • Increased naturalness of sound quality • Elimination of feedback • Easily hidden (covered by hair)

• Improved sound quality of own voice (no occlusion effect) • High-frequencies can be amplified without creating feedback.

TECHNIQUES • Round window vibroplasty (Fig. 7): – Attachment of FMT onto the RW-membrane bypassing the middle ear. • Total/partial ossicular replacement prosthesis (TORP/ PORP) vibroplasty (Figs 8 and 9): – The FMT together with passive ossicular prosthesis used for the reconstruction of the ossicular chain in the middle ear.

SENSORINEURAL HEARING LOSS (Fig. 10)

Fig. 5: Alignment of the floating mass transducer with respect to the ossicular chain

A

• Air conduction thresholds at or within the shaded region • Normal middle ear function as shown by audiometric thresholds, tympanometry and acoustic reflexes • Speech understanding of at least 50% on an open-set word test – At the most comfortable listening level using head phones, or – At 65 decibels sound pressure level (dB SPL) in the free field using hearing aid(s) • Stable hearing loss: Patient should be experienced with hearing aids • No skin conditions preventing attachment of the audio processor

B Figs 6A and B: Differences between (A) acoustic amplification and (B) direct drive

84 Otology and Lateral Skull Base

Fig. 7: Round window vibroplasty

Fig. 8: TORP vibroplasty

CONDUCTIVE AND MIXED HEARING LOSS (FIG. 11)

• Bone conduction thresholds at or within the shaded region • Adequate middle ear space • Absence of active middle ear infection and/or chronic fluid in the ear • Stable bone conduction thresholds • No skin conditions preventing attachment of the audio processor • Realistic expectations • Absence of retrocochlear and central auditory disorders • Eighteen years of age or older.

SURGICAL PROCEDURE Surgical placement of VSB is a very simple procedure that may be performed by any otologist with a standard knowledge of middle ear surgery. Fig. 9: PORP vibroplasty

• Realistic expectations • Absence of retrocochlear and central auditory disorders • Eighteen years of age or older.

Incision The VORP template is placed on the skin with its anterior edge at the postauricular sulcus just behind the ear, and angled approximately 45° posterosuperiorly. The VORP should not lie under the auricle. A marking pen is used to trace the outer perimeter of the template on the scalp.

The Vibrant Soundbridge 85

Fig. 10: Sensorineural hearing loss

Fig. 11: Conductive and mixed hearing loss

The incision is marked at least 2 cm from the edge of the template to minimize the risk of device extrusion and postoperative infection. The incision only needs to be large enough to perform the mastoidectomy, drill the seat for the demodulator portion of the VORP, and suture it to the bone.

The mark on the skull is located and the VORP template is then positioned on the skull surface. The position of the template should be approximately at an angle of 45° as described earlier and the transition, approximately 3 mm from the demodulator, should lie on the posterior edge of the mastoid cavity. Positioning the transition is critical to device placement, and therefore, the final position of the magnet may move slightly anterior or posterior depending upon the size of the mastoid cavity. Instead of drilling a channel between the seat for the demodulator and the mastoid cavity, a bony bridge may be created. By opening this bridge on the superior side, the VORP transition can be easily slide under the bridge, thus giving more protection. The demodulator should also be fixed with sutures. It is important to ensure that there are no sharp edges from the channel or the bridge and that the midpoint of the transition lies on the posterior edge of the mastoid cavity. The VORP template is positioned in the seat to verify the size and depth of the channel. Based on surgical preference, a magnet seat may also be drilled (the magnet may be recessed 1.5 mm) or the receiving coil and magnet portion of the VORP may be placed under a periosteal pocket. Tie-down holes are created on opposing sides of the seat to fix the demodulator. The tie-down holes have to be drilled so that the VORP lies flat when sutured and the VORP transition angles down toward the mastoid cavity (Figs 12A and B).

The “Facial Recess” Route A simple/cortical mastoidectomy is performed just to the point that the short process of the incus is visible. The posterior tympanotomy is not performed at this time to limit bone dust from entering the middle ear. When exposing the antrum, care must be taken to avoid contact of the drill with the incus. Caution: It is advisable to use only a diamond burr when drilling near the facial nerve and the ossicles. The mastoidectomy may need to be extended slightly posteriorly and inferiorly to allow better visualization of the long process of the incus through the facial recess later in the procedure, leaving a bony overhang superiorly and inferiorly.

The “Device-seat” and “Tie-down” Holes The primary objective of creating the device seat is to allow the pre-bent transition of the conductor link to slope deeply into the mastoid cavity so that the conductor link is as medial to the skull surface as possible. The device seat also provides a secure and stable position for the VORP.

86 Otology and Lateral Skull Base

A

B Figs 12A and B: (A and B) Fixing the VORP

Routes to the Middle Ear The Facial Recess Route (Fig. 13) A posterior tympanotomy is created through the facial recess. Care must be taken to avoid the drill contacting middle ear structures. Caution: Use only a diamond burr when drilling near the ossicles. The facial nerve is identified leaving a thin shelf of bone to cover it. The posterior tympanotomy is enlarged to visualize the ossicular chain and extended inferiorly so that the FMT and the forming forceps may be introduced. A 2.5–3.0 mm drill burr, representing the size of the FMT, should be able to pass through the tympanotomy. Care should be taken to preserve the chorda tympani nerve, if possible, while still allowing adequate space for drilling. The buttress between the posterior tympanotomy and the opening of the antrum should be preserved, to avoid damage to the ligament attached to the short process of the incus. The middle ear is then irrigated to remove any residual bone dust.

The Transmeatal Route (Fig. 14) The tympanomeatal flap is elevated to visualize the middle ear space. After identification of the chorda tympani and the annulus, a groove is drilled in the inferior wall of the ear canal. The groove should be 0.5–1.0 mm wide and 2 mm deep. It is safer to drill away from the middle ear to avoid

Fig. 13: The facial recess route

damaging the ossicles. A channel is dissected between the mastoid cavity and the posterior canal wall, allowing placement of the conductor link during FMT installation.

Fixation of Demodulator The VORP is placed over the surgical site so that the magnet protrusion is toward the skull, with the triangle shape on the magnet facing up (Fig. 15). Using a nonresorbable monofilament suture, the demodulator is fixed in place so that it angles down toward the mastoid cavity. The knot is retracted into the suture hole. The suture is centered over the demodulator, and care should be taken that it does not cross the joint between the demodulator and receiving coil nor that between the transitions to the conductor link. Avoid suturing over the receiving coil and magnet.

The Vibrant Soundbridge 87

Fig. 14: The transmeatal route

Fig. 15: Arrangement of the VORP with the triangle shape on the magnet facing upward

It is crucial to correctly position the conductor link to avoid an implant failure. When placing the conductor link, make sure that the lead is not bent.

Floating Mass Transducer Placement in Incus Vibroplasty The FMT is visualized clip under the operating microscope. The clip is carefully opened by sliding a straight needle through the clip opening until the approximate diameter of the long process of the incus is achieved (about 0.5 mm). Pre-bend a small curve in the conductor links a few millimeters from the FMT, so that it does not impede movement of the FMT when in it is final position. With the help of a smooth alligator forceps or a suction tip, the FMT is advanced into the middle ear. Avoid grasping the FMT at its junction to the wire. When the clip is in position over the long process of the incus, it is gently pushed onto the incus with a suction tip or right-angled hook. The clip should be as far superior as possible on the incus, and the axis of the FMT should be parallel to the axis of movement of the stapes.

Opening the FMT Clip with a Straight Needle (Fig. 16) The FMT must be in close contact with the incudostapedial joint and must not contact the promontory, tympanic membrane or pyramidal eminence. The FMT clip is secured in position using the crimping forceps or other otologic forceps (such as stapes wire crimpers or piston-closing forceps) (Figs 17A and B).

Fig. 16: Opening the FMT clip with a straight needle

SUMMARY Till about 15 years ago, the only choice of hearing improvement for moderate sensorineural hearing loss with severe speech discrimination defect was a hearing aid. It was only after Geoff Ball, an electronics engineer who was suffering from a similar defect, started thinking of an alternative to the conventional hearing aid that the vibrant soundbridge came into existence, and with the passage of time the indications for the use of the same have increased.

88 Otology and Lateral Skull Base

A

B Figs 17A and B: Accurate placement of the FMT in close contact with the incudostapedial joint, but not touching the promontory, tympanic membrane or pyramidal eminence

ACKNOWLEDGMENT

REFERENCE

All the images and inputs are taken from MED-EL Medical Electronics.1

1. MED-EL Medical Electronics. [online] Available from http:// www.vibrant-medel.com [Accessed July, 2012].

Totally Implantable Middle Ear Device Esteem 89

CHAPTER

12

Totally Implantable Middle Ear Device Esteem Maurizio Barbara, Claudio Macrì, Simonetta Monini

INDICATIONS FOR THE SURGERY The Esteem is indicated in case of bilateral, not rapidly progressing sensorineural hearing loss.

SPECIFIC PREOPERATIVE EVALUATION

Patients need to have previously experienced conventional hearing aids. If not, they are required to have a preliminary trial with them. Audiological tests include:

• Pure tone audiometry with thresholds within the range indicated in Figure 1: –– Speech Reception Threshold > 40% –– Tympanometry pattern type A (normal) –– Presence of stapedial reflex (when compatible with the hearing threshold) –– Imaging: High resolution CT scan in axial and coronal planes, for measuring specific mastoid areas, as shown in Figures 2 and 3.

ANESTHETIC CONSIDERATIONS The surgical procedure is performed under general anesthesia with hypotensive control, which needs to be continued during all the steps of surgery, especially when cementing is taking place.

SURGICAL STEPS

Fig. 1: In blue, the inclusion area of sensorineural hearing loss for candidacy to the Esteem® (EnvoyMedical) middle ear device

• Identification of a superoposterior—possibly flatretroauricular area in which a bony niche for the Sound Processor (SP) can be drilled. Accordingly, the skin incision is outlined and vasoconstriction solution is injected along it. • Lazy-S retro-auricular incision, including skin and subcutaneous tissue is carried out. • After placement of self-retaining retractors, a large Palva flap is created and elevated with an anteriorlybased pedicle. • The SP bone well is then drilled by using large (6 mm) cutting and diamond coarse burs. On both sides two small holes are drilled for having a suture securing the SP at the end of surgery. • An enlarged mastoidectomy is then drilled, completely exposing the pre-sigmoid region, the sino-dural angle and the inferior cell tip area. • Posterior epitympanectomy is then carried out until getting a complete exposure of the incus body and malleus head with the incudomalleolar joint. • Posterior tympanotomy is then drilled, thinning out but keeping intact the posterior buttress. Inferiorly,

90 Otology and Lateral Skull Base

Fig. 2A: CT axial plane showing the critical length for place­

ment of the driver transducer in a left ear. Measurement is taken from the stapes capitulum to the anterior aspect of the sigmoid sinus. If less than 21 mm, with the presentlyavailable transducers, patients are excluded from surgery

Fig. 2B: Schematic drawing of the size of the driver transducer

Fig. 3: CT axial view showing the critical length for placement of the sensor transducer in a left ear. Measurement is taken from the upper incus body to the sino-dural angle and should not be less than 19 mm, considering the length of the sensor (16.84 mm)

drilling is continued until a gross trapezoidal-shaped opening is obtained at the expense of the chorda tympani nerve, which is severed in almost all cases. The lateral aspect of the posterior tympanotomy will correspond to the fibrous tympanic annulus. The superior corner of the posterior tympanotomy is drilled by obtaining an acute angle. The whole long process of the incus and the pyramidal eminence need to be visualized. • Once placed a microphone in the external auditory canal, two small reflectors are placed on the incus body and on the posterior crus of stapes. By LASER Doppler Vibrometry (LDV), mounted on a second microscope, a first measurement of the intact chain movement is performed, for assessing an efficacious motility of the eardrum/ossicle complex, which will guarantee a proper function of the microphonic system to be captured by the sensor transducer. • By using fine angled hooks, mucosa is then gently removed from the incudostapedial joint area, going latero-medially towards the stapedial tendon. The incudostapedial joint is then separated and by surgical LASER, the long process of the incus is amputated.

Totally Implantable Middle Ear Device Esteem 91 • Mucosa from the stapes capitulum is then carefully scraped away and final drying is achieved by applying low-power LASER beam. • A drop of EnvoyCem is then applied on stapes capitulum and the precoat is obtained. • Both sensor and drivers transducers are then attached to the Glasscock stabilizers screwed on the posterior edge of the mastoidectomy cavity. They are then placed, respectively on the incus body and on the precoated stapes capitulum. • MedCem is then poured on the mastoidectomy cavity for fixing the transducers’ bodies in place. • EnvoyCem is then placed to cement the tip of the driver on the pre-coated stapes capitulum, as well as between the sensor tip and the incus body, followed by creation of a new joint. • LASER Doppler Vibrometry (LDV) measurements are then performed, by testing both sensor and driver efficiency. • The SP is then put in place and attached to the sensor and driver cables. Final LDV measurements of the whole system are carried out. • Closure is performed in three layers.

NEW TECHNIQUES IN THE SURGERY In order to keep the microphone in place inside the external auditory canal, a suture is placed between tragus and antitragus.

COMPLICATIONS

• Malfunctioning of the device may occur and require surgical revision with total or partial substitution of the transducers. • Mechanical feedback due to fibrous tissue overgrowth may occur and require surgical revision. • SP dehiscence may also occur and need surgical revision.

SPECIAL INSTRUMENTS USED FOR THE SURGERY

• LASER Doppler Vibrometry (LDV) for carrying out measurements of the mobility of the eardrum and ossicular chain. • Surgical LASER, such as diode LASER.

OTHER TREATMENT OPTIONS AVAILABLE FOR THE SAME CONDITION

• At the present, a moderate-to-severe sensorineural hearing loss may achieve benefit from implant of the Carina, totally-implantable middle ear device, which encompasses also the implantation of a microphone in the retroauricular region and, differently from Esteem, requires daily recharge of the battery.

CHAPTER

13

The Surgical Management of Cholesteatoma T Nikolopoulos, P Gerbesiotis

INDICATIONS FOR THE SURGERY Even though cholesteatoma is not a new entity in the specialty of otology, it continues to present with certain management challenges. Chronic otitis media with cholesteatoma is considered an “unsafe” ear and generally requires surgical management to avoid important complications. Recurrence and recidivism can befuddle even the most experienced surgeon. Subsequently, otorhinolaryngology specialty is constantly trying to devise new approaches to increase visualization and effectively eradicate the disease, while also maximizing hearing and creating a maintenance-free ear. Although there are some absolute and relative indications for mastoidectomy, the type of surgery is based on the extent of disease, preoperative health of the patient, the status of the opposite ear, and both the surgeon’s and patient’s preferences. A cholesteatoma is per se an absolute indication for surgery. However, the presence of complication suggests that the operation should be performed as soon as possible. On the other hand, a small, slow-growing cholesteatoma in an elderly patient with other serious medical problems may be an indication for follow-up. There are different approaches used worldwide and each surgeon has his own beliefs and conceptions/ misconceptions.

SPECIFIC PREOPERATIVE EVALUATION

Preoperative planning includes a comprehensive otomicroscopic examination. Attic retraction pockets should be viewed with suspicion if the surgeon is unable to see the depth of the pocket. Using a right-angled pick, to feel the depth of such a retraction, is often helpful. The use of otoendoscopes has been quite helpful in permitting a “fish-eye” view of these pockets. Active infections are treated aggressively with topical antibiotic drops before surgery. Bilateral full audiometric evaluation is performed in all cases. Occasionally, the hearing test will result in a

change of approach to the surgery. The fistula test should be performed, particularly if there is a history of vertigo, although it can be negative where a labyrinthine fistula is present. Computed tomography (CT) scans can help delineate the bony anatomy of the temporal bone and this evaluation is recommended especially in cases of children with congenital malformations, in patients with symptoms consistent with a labyrinthine fistula or other possible complications (facial paralysis, meningitis or other intracranial complication), and in revision surgery. However, CT scan has certain limitations as it may seriously mislead the surgeon. Maybe, the negative imaging is more helpful than the identification of a mass in the mastoid that may be granulation tissue and not a cholesteatoma. Magnetic resonance imaging (MRI) and especially modern techniques of MRI (e.g. single-shot turbo spinecho diffusion-weighted MRI) may be useful for detecting recurrent cholesteatomas behind an intact graft, although such techniques have not been widely used yet.1 Several times, the diagnosis is doubtful and the patient should be listed for an exploration of the affected ear and only at the time of surgery, the diagnosis and the extent of surgery will be determined. All patients should be encouraged to stop smoking because it may increase recurrence rate.2

ANESTHETIC CONSIDERATIONS The most important part of the anesthetic is smooth induction and keeping the blood pressure low, as it seems to be the only common factor in obtaining relatively bloodless surgery. The tragus and the area of the incision are injected with 2% lidocaine with 1:100,000 epinephrine about 10–15 minutes before the start of the case to allow proper hemostasis, deep enough to infiltrate down to the mastoid bone. Transcanal injection of the posterior ear canal with 2% lidocaine and 1:50,000 epinephrine is performed. When retroauricular incision is indicated, about 10 mL of the anesthetic solution is injected along the incision line near the retroauricular fold. From the same region,

The Surgical Management of Cholesteatoma 93 the needle is advanced anteriorly, and a few ml of the anesthetic solution is injected subperiosteally to the canal skin through the canal. Antibiotics are routinely given peri­operatively to reduce infection risks.3 Steroids may also be used to reduce postoperative nausea or limit the possibility of facial nerve palsy when there is a risk of thermal or other injury. If facial nerve monitor is used (most often in difficult cases or revisions or posterior tympanotomy approaches), anesthesia should not use agents interfering with nerve monitoring.

SURGICAL STEPS The main objective is to create a safe and dry ear by eradicating the disease and secondary to maintaining or (if possible) improving hearing. Besides the total cholesteatoma removal, mastoid surgery methods aim for single or minimum number of operations, minimal recurrence rate, easily cleaned cavity and in general, a good quality of life. Firstly, the authors present the different types of mastoidectomy and secondly, they analyze the surgical steps.4

The Simple Mastoidectomy It is mainly used to unroof the mastoid cortex and drain a coalescent mastoiditis with subperiosteal abscess.

Intact Canal Wall or Canal Wall Up Mastoidectomy The posterior ear canal wall is preserved. A posterior tympanotomy is usually included, as well as an elevation of the posterior tympanomeatal flap (combined approach).

limits of the cholesteatoma sac. If needed, limited drilling of the mastoid cavity is performed, following the sac from inside-to-outside direction. The defect may be reconstructed with a cartilage graft or autologous bone. Otherwise, a piece of temporalis fascia is placed over the defect.

Surgical Incision/Approach Once the patient is prepped and draped, local injection should be performed with 1–2% lidocaine with 1:100,000 dilution epinephrine for vasoconstriction. The standard postauricular incision and the endaural incision are the two basic incisions for access to the mastoid.

Postauricular Incision This one spans from the helical rim to the mastoid tip (Fig. 1). It should be about 1 cm behind the postauricular crease so as to avoid unsightly deepening of the sulcus, which can occur when incisions are placed directly in the crease.5 Especially in young children, it should be more posterior so as to avoid a superficial facial nerve near the mastoid tip. The No. 15 blade should be used to make the incision. The blade should be used to carry the incision down to the level of the temporalis fascia. Blunt dissection with a finger should be easily accomplished in this plane so as to elevate flaps anteriorly and posteriorly. Monopolar cautery is used to control bleeding. An avascular plane is elevated anteriorly toward the EAC just below the subdermal fat, leaving a layer of loose areolar tissue on the temporalis fascia. A self-retaining retractor is spread over the temporalis muscle. A large graft temporalis fascia or/and areolar fascia graft are harvested

Canal Wall Down Mastoidectomy The posterior ear canal wall is not preserved and in the majority of cases, this type of mastoidectomy is combined with tympanoplasty.

Radical Mastoidectomy The mastoid antrum, tympanum and external auditory canal (EAC) are converted into a common cavity exterio­ rized through the external meatus. This operation involves removal of the tympanic membrane and ossicular remnants, with exception of the stapes (if possible), and does not involve any reconstructive or grafting procedure. A tissue plug or graft is usually placed to seal the orifice of the Eustachian tube.

Atticotomy/Limited Mastoidectomy In this mastoid procedure, usually, only a limited portion of the posterior wall of the EAC is sacrificed. A small attic cholesteatoma is removed by drilling the scutum to the

Fig. 1: Postauricular incision Source: Glasscock ME, Gulya AJ. Glasscock-Shambaugh Surgery of the Ear. 2002

94 Otology and Lateral Skull Base with a scalpel and scissors (Fig. 2). For proper healing, the grafts must be thinned of all muscle and fat attachments. Alternatively, tragal perichondrium may be harvested for grafting. As shown by the dashed lines in the Figure 2, “T” shaped incisions are then made through the mastoid perio­steum with electrocautery. The horizontal incision is made just below the temporalis muscle in the linea temporalis. A second incision is made perpendicular to the first in the middle of the mastoid, extending from the temporalis muscle to the mastoid tip. An elevator is then used to elevate the perio­steum. Two self-retaining retractors are often placed in orthogonal directions. Bleeding from veins may be controlled either

Fig. 2: Temporalis fascia graft harvest and periosteal incisions Source: Glasscock ME, Gulya AJ. Glasscock-Shambaugh Surgery of the Ear. 2002

Fig. 3: The authors prefer to begin the endaural incision from the inside of the external auditory meatus (EAM) at the 12 o’clock position with the help of an endaural speculum

with cautery or with bone wax when bone is involved. It is important, during this step, to leave a sizable flap so as to facilitate closure at the end of the procedure.

Endaural Incision T h e second basic type of incision during cholesteatoma surgery is the endaural approach.6 Anterior to the helix, an incision is made with a No. 15 blade through the skin following the curve of the helix for about 1 cm from the inside of the external auditory meatus (EAM) at the 12 o’clock position (Fig. 3). The authors retract the pinna posteriorly in order to protect the cartilage of the helix, while performing the endaural incision (Fig. 4). The authors extend the skin incision into the EAM to the bony portion and then make a circumferential incision parallel to the annulus until the lowermost point on the floor of the EAM (Figs 5 and 6). The anterior auricular vein is identified, diathermied and divided. The anterior auricular muscle is divided and then the temporalis muscle fascia is identified. A dense layer of areolar tissue, suitable as graft material, overlies the actual fascia and may be utilized if thick enough. Alternatively or in addition, the authors take the fascia itself using nontoothed forceps and a scalpel with No. 15 blade (a roughly-circular graft, as large as possible, using the full extent of the incision) (Fig. 7); they trim off any fat or muscle with a scalpel blade and thin the graft either using a vein pressor (large enough) or pressing the graft with a gauge against a hard surface. Finally, the graft is left to dry. In some cases, the authors take conchal or tragal cartilage for grafting. Hemostasis should be secured to prevent hemorrhage into the operative field during surgery.

Fig. 4: Retraction of the pinna posteriorly to protect the cartilage of the helix while performing the endaural incision

The Surgical Management of Cholesteatoma 95

Fig. 5: Diagram of an endaural incision

The underlying soft tissue and periosteum are elevated and put aside using a raspatory, exposing the suprameatal spine and tympanomastoid fissure. A small portion of the mastoid cortex will be exposed as well. Two self-retaining retractors, vertical one to the other, are used to expose widely the authors’ field.

Fig. 6: A circumferential incision parallel to the annulus from the 12 o’clock position until the lowermost point on the floor of the external auditory meatus (EAM), 6 o’clock position, using a small elevator

Source: Nikolopoulos TP, Gerbesiotis P. Surgical manage­ ment of cholesteatoma: the two main options and the third wayatticotomy/limited mastoidectomy. Int J Pediatr Otorhi­ nolaryngol. 2009;73(9):1222-7

Surgical Methods Introduction All drilling is done under the microscope with binocular vision. Constant irrigation is critical to prevent thermal damage from the drill bits. Initially, cutting burrs are used to remove bone and identify important landmarks. Diamond burrs are then used for more delicate procedures like working near the sigmoid sinus or the facial nerve. Periodic irrigation of the surgical field with saline solution reduces bleeding and washes debris from wound. The key to a safe dissection is identifying key structures. Identifying the tegmen, EAC, sigmoid sinus, middle ear ossicles and facial nerve is the easiest and safest way to ensure their preservation. Identification of anatomical landmarks is the most important element in cholesteatoma surgery and even the most experienced otologists may be lost in the tiny area of the middle ear with dramatic consequences.

Fig. 7: Preparation of taking the temporalis fascia Source: Nikolopoulos TP, Gerbesiotis P. Surgical manage­ ment of cholesteatoma: the two main options and the third wayatticotomy/limited mastoidectomy. Int J Pediatr Otorhi­ nolaryngol. 2009;73(9):1222-7

Simple Mastoidectomy

Intact Canal Wall Up Mastoidectomy— Posterior Tympanotomy—Combined Approach

It is mainly used to unroof the mastoid cortex and drain a coalescent mastoiditis with subperiosteal abscess. It is not used in cholesteatoma surgery. Therefore, it is not described in detail in the present chapter.

Dissection starts high in the mastoid cortex, removing bone along the linea temporalis until a thin layer of tegmen bone is left over the middle fossa dura, remembering that tegmen height is variable depending on mastoid

96 Otology and Lateral Skull Base pneumatization. The next structure, visualized deep in the mastoid cavity, is Korner’s septum, the remnant of the petrosquamous suture line. Once through Korner’s septum, the lateral semicircular canal is visible on the medial side of the antrum. The otic capsule is easily distinguished from the mastoid air cells by its smooth glistening appearance. At this point during the dissection, the surgeon may wish to change to a smaller cutting burrs to better define the antrum. Alternatively, a curette may be used. For proper exposure, it is critical at this point to thin the posterior EAC. As dissection is continued medially, the epitympanum is opened and both the incus and a small part of the malleus are partially visualized. If necessary, air cells lateral to the labyrinth are exenterated down the mastoid tip where the digastric ridge is identified (Fig. 8). Before cholesteatoma dissection, bone is removed circumferentially around the cholesteatoma sac avoiding direct contact with the sac. Once fully exposed, the authors attempt to remove the cholesteatoma with its sac intact. If this is not possible, the cholesteatoma sac is opened and the squamous debris removed to facilitate dissection. Because labyrinthine fistulas are difficult to assess preoperatively, careful examination of medial surface of the cholesteatoma sac is performed, looking for flattening of the lateral semicircular canal or defects in its surface, which may indicate an underlying fistula. Areas of suspected fistula can be palpated carefully with blunt instruments before removing the cholesteatoma as this may open, widely, the semicircular canal with dramatic consequences to the labyrinth. Sometimes, leaving a small matrix on the fistula is the procedure of choice, preserving labyrinthine

function in 93% of patients as opposed to only 80% if the matrix is removed.7 Of course, these percentages vary widely and may be underestimating the actual risk. Therefore, we should take as a fact that such fistulas are highly dangerous for permanent loss of cochlear and vestibular function. If the fistula area is very small, many otologists remove, very carefully, the matrix and plug immediately the fistula with soft tissue. Otherwise, the matrix should be left in place. Nevertheless, the risk, more or less, for permanent hearing and vestibular loss exists anyway. Some otologists suggest that if less than 2 mm of matrix is left, a canal wall intact procedure can be performed if a second stage is planned. A canal wall down (CWD) procedure should be performed if a large cholesteatoma matrix is left in the mastoid.8 Other otologists consider any fistula as an indication for CWD procedures. After having completed the mastoidectomy, the authors continue the dissection by performing posterior tympanotomy. The facial recess is an inverted triangle bounded posteromedially by the facial nerve, anterolaterally by the chorda tympani nerve and superiorly by the incus buttress. The first step in safely performing a facial recess is to ensure that the posterior EAC is thinned appropriately at the end of a complete mastoidectomy. The next step is identification of the facial nerve using previously found landmarks, including the lateral semicircular canal and the short process of the incus (Fig. 9). The facial nerve is always found inferomedial to the lateral semicircular canal (Fig. 10). Using a large diamond burr and copious amounts of irrigation, the facial nerve is identified throughout its entire mastoid course, from the second genu just inferior

Fig. 8: Mastoidectomy in cholesteatoma dissection. (Asterisk

Fig. 9: Facial recess. Short process of the incus (dashed line) helps identify the facial nerve

indicates lateral semicircular canal; EAC: External auditory canal) Source: Glasscock ME, Gulya AJ. Glasscock-Shambaugh Surgery of the Ear. 2002

Source: Glasscock ME, Gulya AJ. Glasscock-Shambaugh Surgery of the Ear. 2002

The Surgical Management of Cholesteatoma 97

Fig. 10: Canal wall up (CWU) cavity in a temporal bone

Fig. 11: Inferior extended facial recess. (Asterisks indicate sacrificed chorda tympani nerves) Source: Michael E Glasscock, Aina Julianna Gulya. GlasscockShambaugh Surgery of the Ear. 2002

to the lateral semicircular canal. Using strokes, always parallel to the direction of the nerve, the nerve is traced out, leaving a thin layer of the fallopian canal bone intact over the nerve. The surgeon must be aware of a possible lack of bony covering, or dehiscent, facial nerve in the mastoid. Some otologists do not necessarily identify the facial nerve, but follow the two-third to one-third rule— that is drilling parallel to the facial nerve and two-thirds over the line that is derived from the line derived from the short process of the incus and one-third under this line. Next, the chorda tympani nerve may be identified as the anterior branch of the facial nerve. Dissection proceeds between the facial nerve and the position of the chorda tympani nerve superiorly where the recess is the widest until the middle ear is entered. A short bridge of bone, the incus buttress, is left in the superior part of the facial recess to protect the incus from the drill and maintain the support for the incus. This method is almost always combined with the elevation of a posterior tympanomeatal flap, for further exploration of the middle ear (combined approach). Then, the incus buttress can be removed with a small diamond burr. After removal of the incus and head of the malleus, the epitympanum can be better assessed. Inferiorly, an extended facial recess can expose the hypotympanum. The chorda tympani nerve is skeletonized and sacrificed sharply to avoid retrograde trauma to the facial nerve. Dissection proceeds between the facial nerve and the tympanic membrane annulus (Fig. 11). After removing the cholesteatoma, appropriate tympanoplasty-ossicular chain procedures are used.

At the completion of the procedure, the mastoid periosteum is reapproximated with several interrupted 3-0 Vicryl sutures. If a postauricular incision has been used, a wide canaloplasty is performed. This is not necessary if an endaural incision has been used. The skin is closed with interrupted 3-0 nylon sutures. Pieces of gelfoam are placed in the external ear canal, as well as a ribbon gauge dressing with ointment. A mastoid dressing is then placed on the patient prior to awakening, using fluffed 4 × 4’s and roller gauze to create a tight pressure dressing. Most otologists recommend a second look procedure 6 months to 1 year after the first procedure in order to exclude a residual cholesteatoma.

Canal Wall Down Mastoidectomy Several of the surgical steps described in the canal wall up (CWU) mastoidectomy are applicable in this procedure as well. The goal of the CWD mastoidectomy is to create a smooth cavity with no corners, edges, or depressions in which debris can accumulate. The incudostapedial joint is usually separated, and both the incus and the head of the malleus are usually removed. The EAC is then removed completely to the level of the fallopian canal, first with a large cutting burr and later with a diamond burr, always drilling parallel to the facial nerve (Fig. 12). If the air cells in the mastoid tip are diseased, they are completely exenterated to avoid dependent tip infections. The overall goal is to have one smooth cavity with no edges (Fig. 13).

98 Otology and Lateral Skull Base

Fig. 12: The posterior external auditory canal (EAC) wall must be lowered to the visible facial nerve. The chorda tympani is sacrificed. Canal wall flaps are preserved Source: Glasscock ME, Gulya AJ. Glasscock-Shambaugh Surgery of the Ear. 2002

Fig. 13: Both the incus and the head of the malleus are usually removed during CWD procedure Source: Glasscock ME, Gulya AJ. Glasscock-Shambaugh Surgery of the Ear. 2002.

If a postauricular incision has been used, a large meatoplasty is necessary for epithelialization of the cavity and easier postoperative care. Generally, the meatus initially should be made about the size of the mastoid cavity because it will undergo about 25% contraction over time. A good approximation of this size is the surgeon’s thumb.

Radical Mastoidectomy

Fig. 14: The graft is placed underlay to the tympanic membrane remnant, superiorly over the labyrinth and posteriorly over the facial ridge. The graft is applied directly atop the stapes superstructure

The radical mastoidectomy is an operation performed to eliminate all middle ear and mastoid disease through complete removal of mucosa, tympanic membrane, annulus, malleus and incus. Dissection is performed in a fashion similar to the CWD mastoidectomy, but there is no attempt for reconstruction or tympanic membrane grafting. In addition, the Eustachian tube is occluded with a fascial plug. This operation, these days, is very rarely performed.

Source: Glasscock ME, Gulya AJ. Glasscock-Shambaugh Surgery of the Ear. 2002

Canal Wall Down Versus Canal Wall Up/The Controversy

Care must be taken, inferiorly, to avoid injury to a high jugular bulb in the hypotympanum. The ossicular chain may be reconstructed and a large fascial graft is used to recreate the tympanic membrane (Fig. 14). For educational reasons, in Figures 15 and 16, we can identify a CWD cavity in a temporal bone with emphasis in middle ear anatomy (firstly, with the ossicular chain intact and secondly, after removing the incus).

Canal wall down mastoidectomy is the most widely used surgical method worldwide. It is supposed to be easier, of shorter duration and necessitate less surgical experience than the CWU procedures. The anatomic and functional outcome is satisfactory, and the rate of complications is acceptably low.9 The primary advantage of a CWD procedure is increased visibility and adequate access to the mesotympanum and epitympanum. This increased exposure accounts for reduced rates of recurrence versus intact

The Surgical Management of Cholesteatoma 99

Fig. 15: Canal wall down (CWD) cavity in a temporal bone

Fig. 16: Canal wall down (CWD) cavity in a temporal

with the ossicular chain intact and a promontory cochleostomy

bone, after removing the incus

canal wall procedures.2 CWD procedure is supposed to be the unique solution for cholesteatomas in certain cases, such as the only hearing ear, when there is a labyrinthine fistula, etc. Hulka and McElveen claimed that CWD procedures do permit visualization of the anterior epitympanum and sinus tympani region (the latter is not fully visualized with any technique).10 Another relative indication for CWD mastoidectomy is failure of previous CWU procedures with recurrent cholesteatoma. However, postoperative care is more intense in the CWD surgery, both in the immediate postoperative period and long term. In contrast, the intact canal wall mastoidectomy maintains the natural anatomy and heals more quickly than the CWD mastoidectomy. Canal wall intact procedures do not require regular debridements, and hearing outcomes tend to be slightly improved over CWD procedures, although this is not accepted by all otologists.11 Hearing aid fitting after CWU surgery is generally straightforward and associated with fewer complications than that after CWD tympanomastoidectomy. On the other hand, contraindications for CWU are the extremely sclerotic mastoid, the significant posterior canal wall erosion, the presence of matrix over lateral canal fistula and the location-size of cholesteatoma, the Eustachian tube dysfunction and the occurrence of complications. Some surgeons attempt a canal wall reconstruction (CWR) tympanomastoidectomy with mastoid obliteration technique in order to reduce the size of mastoid cavity and provide a more “normal” postoperative anatomy. Materials, such as bioactive glass ceramic, have also been used in order to reconstruct the canal wall.12 Moreover, postoperative vertigo in CWD revision surgery has been clearly diminished due to the mastoid obliteration.13 CWR procedure can be used for all patients with acquired

cholesteatoma, including children.14 Some surgeons propose a different procedure, the canal wall window (CWW) technique, which involves slitting the posterior canal wall. They claim that it provides good hearing results, especially in a young population who will bear the surgical outcome for many decades.15 The above mentioned methods attempt to improve CWD techniques, although sometimes they may cause more problems than solve. Nevertheless, the debate is still on due to new evidence, better imaging, high-tech endoscopes and intraoperative use of facial nerve monitoring. Last but not the least, with the introduction of smaller cavity surgery, reconstruction surgery, CWW technique and the many obliteration techniques, the distinction between CWU and CWD surgery tends to become blurred. It has also become clearer that the outcomes of cholesteatoma surgery are highly ope­rator dependent.

Atticotomy—Limited Mastoidectomy—The Third Way in Cholesteatoma Surgery The aim of this field is to present a different way of surgical management—the inside-outside approach through an endaural incision. This technique includes atticotomy, atticoantrostomy or mastoidectomy (mostly very limited) according to the size and location of the cholesteatoma. This technique aims at successful surgical management of cholesteatoma, eradicating the disease with the creation of small, dry, often self-cleaning cavities and no pinna protrusion. An endaural incision has the advantage of being small and if well performed, healing with practically no scar. Moreover, there is no need for meatoplasty. Firstly, the authors perform an endaural approach (they have already prescribed this type of incision above). Using a Rosen’s elevator or small periosteal elevator, they

100 Otology and Lateral Skull Base elevate the skin off the posterior meatal wall and then elevate inferiorly to free the skin from the floor of the EAC. Using iridectomy scissors, the authors remove a triangle of skin, with the base at the superior posterior rim of the circumferential incision and its tip at the spine of the Henle. Removal of this superficial meatal skin posteriorly improves surgical access and prevents the mastoid cavity being lined with hairs and ceruminous glands. The view may be obstructed by a prominent suprameatal spine or

by a bulging bony anterior external meatus, which have to be drilled away.16 Using a round knife or small round elevator and a piece of cotton wool with adrenaline, the posterior tympanomeatal flap is elevated (Figs 17 and 18). Finding the annulus, with a curved needle, the authors enter the middle ear. Then, they approach the attic and the scutum is removed very carefully using, in the beginning, regular burrs, and finally diamond burrs in order to protect the ossicles (Figs 19 and 20).

Fig. 17: Diagram showing the elevation of the posterior tympanomeatal flap

Fig. 18: Elevation of the posterior tympanomeatal flap using a round knife. This picture depicts the erosion of the posterior ear canal due to an extended cholesteatoma

Source: Nikolopoulos TP, Gerbesiotis P. Surgical manage­ment of cholesteatoma: the two main options and the third way-atticotomy/limited mastoidectomy. Int J Pediatr Otorhi­nolaryngol. 2009;73(9):1222-7

Fig. 19: Removing the external wall of the attic giving direct access to the cholesteatoma

Source: Nikolopoulos TP, Gerbesiotis P. Surgical manage­ment of cholesteatoma: the two main options and the third way-atticotomy/limited mastoidectomy. Int J Pediatr Otorhi­nolaryngol. 2009;73(9):1222-7

Fig. 20: The black arrow in the CT scan points the scutum that needs to be removed in order to approach the attic and the cholesteatoma (CH) sac Source: Nikolopoulos TP, Gerbesiotis P. Surgical manage­ment of cholesteatoma: the two main options and the third way-atticotomy/limited mastoidectomy. Int J Pediatr Otorhi­nolaryngol. 2009;73(9):1222-7

The Surgical Management of Cholesteatoma 101 Sometimes, a House curette is used to remove the last remnants of the scutum. This part of the operation, especially in inexperienced surgeons, has the risk of causing sensorineural deafness if the burr inadvertently hits the ossicles. The body of the incus is the first ossicle to be visualized during atticotomy. If the cholesteatoma involves the incus, then the latter is disarticulated from the stapes (although in most cases, the long process of incus has already been eroded) and the malleus. This allows a wider exposure. If the head of the malleus is also involved,

Fig. 21: An intraoperative view of a limited attic cholesteatoma (CH). (BI: Body of incus; CT: Coloboma of chorda tympani) Source: Nikolopoulos TP, Gerbesiotis P. Surgical manage­ment of cholesteatoma: the two main options and the third way-atticotomy/limited mastoidectomy. Int J Pediatr Otorhi­nolaryngol. 2009;73(9):1222-7

Fig. 22: A view of a limited cholesteatoma after having elevated the posterior tympanomeatal flap in a temporal bone

it is removed using a House-Ditter instrument. Then, the authors follow the cholesteatoma sac and the bone removal is usually determined by the extent of the disease (Figs 21 and 22). The procedure is progressive, anteriorto-posterior dissection, exposing the cholesteatoma, thus creating atticotomy, atticoantrostomy and if needed, mastoidectomy. Following the cholesteatoma and removing as much bone as needed allows creating the smaller mastoid cavity possible.17 In order to avoid tearing the sac, it can be elevated from the bone using a House whirlybird. Undoubtedly, keeping the sac intact makes following it easier and complete removal more likely (Fig. 23). Where there is an extensive mastoid involvement (Fig. 24), the posterior meatal wall is totally removed and the facial ridge is taken down to the floor of the EAM; thus, the mastoid cavity does not form an independent sump. However, in many cases, only a limited or no mastoidectomy is necessary. If an extensive mastoidectomy is performed, one of the most important factors influencing the outcome of a dry ear is adequate lowering of the facial ridge. However, special attention should be exercised in the area of the facial nerve because the nerve may be dehiscent or camouflaged by white cholesteatoma matrix or by granulations that are often firmly adherent to the facial nerve or other underlying structures and quite often hemorrhagic. If bleeding is troublesome, it is advisable to apply a pledget soaked in 1:1,000 solution of adrenaline and leave it for 3 minutes. The round window is usually protected by a bony overhang; the bone over the promontory may have been eroded, so dissection must be gentle. Occasionally, the

Fig. 23: An intraoperative view of removing a cholesteatoma (CH) through an atticotomy. (BI: Body of incus; CT: Coloboma of chorda tympani) Source: Nikolopoulos TP, Gerbesiotis P. Surgical manage­ment of cholesteatoma: the two main options and the third way-atticotomy/limited mastoidectomy. Int J Pediatr Otorhi­nolaryngol. 2009;73(9):1222-7

102 Otology and Lateral Skull Base sac invades the Eustachian tube and it should be carefully removed from the area along with any granulations blocking the opening of the Eustachian tube. Labyrinthine fistula should be suspected in all cases of cholesteatoma, the most likely site being the lateral semicircular canal. In most cases, tympanoplasty is performed (type III if possible), using temporalis fascia (Fig. 25). Alternatively, the authors use tragal or conchal cartilage (Figs 26 and 27).18 The graft should be placed as underlay from the posterior edge of the tympanic remnant anteriorly to the bony facial canal posteriorly, laid on a bed of surgical sponge. It should

be supported with small pieces of surgical sponge. When healed, the tympanic membrane and EAM will appear nearly normal. Ideally, the middle ear cleft should be left as an air-containing cavity not open to the EAM. The skin incision should be closed with a continuous subcuticular 4/0 PDS, starting superiorly and finishing in the EAC. Six inches (15 cm) of a half-inch Bismuth, Iodoform and Paraffin Paste (BIPP) pack is inserted gently and not packed tightly on top of gelfoam pieces. Cotton wool can be applied on top. A gauze dressing should then be applied to the pinna.

Fig. 24: An intraoperative view of an extended cholesteatoma that has eroded the ossicles

Fig. 25: Postoperative ear with temporalis fascia (tympanoplasty type III)

Source: Nikolopoulos TP, Gerbesiotis P. Surgical manage­ment of cholesteatoma: the two main options and the third way-atticotomy/limited mastoidectomy. Int J Pediatr Otorhi­nolaryngol. 2009;73(9):1222-7

Fig. 26: Appropriate incision in order to take the tragal cartilage

Fig. 27: Postoperative ear with perichondrium/cartilage island graft (left ear)

Source: Dornhoffer JL. Cartilage tympanoplasty. Otolaryngol Clin North Am. 2006;39(6):1161-76

Source: Dornhoffer JL. Cartilage tympanoplasty. Otolaryngol Clin North Am. 2006;39(6):1161-76

The Surgical Management of Cholesteatoma 103

Postoperative Care

Hearing Loss

As soon as the patient is awake, Weber, nystagmus and facial nerve function are assessed. Both immediate and long-term care are important in the mastoidectomy patient. Nausea and pain are treated aggressively to make the patient comfortable. Patients are discharged with the ribbon gauge in place after removal of the gauge dressings 24 hours following surgery. Patients are instructed to change cotton wool balls over the ribbon gauge and keep the incision clean (the latter should be covered by steristrips changed every 1 or 2 days). Follow-up is scheduled firstly in 7–10 days (to carefully remove the ribbon gauge) and secondly in 3 weeks time. Water precautions are suggested. The patient is warned about signs of complications (otorrhea, headache, vertigo, dizziness, hearing deterioration, high temperature, etc.).

Sensorineural hearing loss (SNHL) is usually the result of removal of cholesteatoma over labyrinthine fistulas or inadvertent contact between the drill and ossicular chain during dissection. Labyrinthitis may also lead to SNHL as inflammatory agents enter the inner ear via the round or oval windows. Drill injuries usually result in highfrequency SNHL.

COMPLICATIONS Facial Nerve Injury Facial nerve monitor is supposed to be an important tool in avoiding facial nerve injury during difficult cases of mastoidectomy. However, monitoring is not a substitute for thorough knowledge of the anatomy of the nerve or for surgical experience, or for a meticulous and careful procedure. If nerve injury is suspected intraoperatively, identification of the nerve is performed. Injury to the epineurium or nerve sheath usually has no long-term consequences and no further treatment is necessary other than the decompression already performed, postoperative steroids and close follow-up. If the nerve is found cut, primary reanastomosis through simple reapproximation in the fallopian canal or several 9-0 sutures through the epineurium should be performed if there is enough length of nerve present. If there is a segment of nerve missing, mobilization of the nerve may obtain the extra length needed for anastomosis. If more length is still needed, a cable graft using the great auricular or sural nerve may be used. Immediate facial paralysis in the postoperative period also requires prompt evaluation. Several hours may pass to ensure paresis is not the result of overzealous use of local anesthetic at the beginning of the case or of a tight pack compressing the nerve. If paralysis persists beyond 4 hours, prompt operative exploration of the nerve is warranted. However, partial paralysis indicates that nerve is not cut but injured. In these cases, steroids, antibiotics, removal of a tight packing and follow-up are indicated. Conservative management, at least initially, with steroids, antibiotics and antivirals is warranted in all cases of delayed facial paralysis.19

Infection Postoperative infections occur in 2–5% of mastoidectomies. Infection may be the result of wound infection or continued chronic ear disease. Routine prophylaxis may not necessarily reduce postoperative infection rates.20 Perichondritis occurs in approximately 1% of CWD procedures; therefore, perioperative antibiotics are used routinely in these procedures. Infections in a mastoid with exposed dura may predispose the patient to meningitis and brain abscesses. Labyrinthitis may also occur with dramatic consequences.

Vertigo In the immediate postoperative, period nystagmus, nausea and vomiting are all more likely to be due to the effects of the anesthetic. If these have not settled by the following day, someone could assume an otogenic cause. Labyrinthine fistulas and injuries during mastoid surgery may cause vertigo following mastoidectomy (Fig. 28).21 Labyrinthitis may also cause vertigo. However, suction in the operated ear most often causes dizziness and vertigo to the patient without suggesting a complication.

Fig. 28: Intraoperative picture of a horizontal canal fistula Source: Smith JA, Danner CJ. Complications of chronic otitis media and cholesteatoma. Otolaryngol Clin North Am. 2006;39(6):1237-55

104 Otology and Lateral Skull Base Chronic infection may also be a source of reduced vestibular function. Although unilateral loss of vestibular function may occur, chronic disequilibrium is rare.

Intracranial Injury Exposure of dura generally is avoided and usually small exposures are covered by temporalis fascia grafts. Usually, dura exposure is not of serious consequence, unless large defects in the tegmen, dural abrasions or cerebrospinal fluid are encountered.

Bleeding Like any surgery, bleeding is a potential postoperative risk. In modified radical and radical mastoidectomies, postoperative bleeding is greater owing to more soft tissue dissection; however, blood drains through the meatus and there is little risk for hematoma formation. Injury to large vascular structures like the sigmoid sinus, jugular bulb, or large emissary veins mandates immediate assessment. Bleeding often is controlled easily with gelfoam and gentle pressure.

Chronic Aural Discharge The most common cause of postmastoidectomy aural discharge is a high facial ridge. If the facial ridge has been properly lowered, then residual cholesteatoma should be suspected (which would require revision surgery). A cavity that fills with wax and is not self-cleaning may also give rise to intermittent infections. Discharge may also occur if the middle ear cleft has not been grafted or the graft has broken down. Revision tympanoplasty should be considered in these cases.

SPECIAL INSTRUMENTS USED FOR THE MIDDLE EAR SURGERY

There are different sets for different otosurgical procedures. We strongly recommend relatively small sets to avoid any loss of time searching for the required instrument and parallel makes assisting the surgeon much easier. • Facial nerve monitor (esp. for revision surgeries, middle ear malformations and educational reasons) • Self-retaining retractors, sharp retractor: expose widely the surgical field • Preparation plate—Teflon bed: preparation of grafts • Seeker 45°, ear hook size 1, picks 90° 0.4–1 mm : exploration of middle ear cavity • Light curve needle: entering the middle ear after finding the annulus • Plester and Rosen’s elevator • Nasal speculum, Ear specula OD 5–7.5 mm

• Small round knife 45°: elevation of posterior tymp­ anomeatal flap • Sickle knife • Curette (Large-small size): removal of bone remnants safely • Scissors (curved-straight) • House whirlybird: elevation of the cholesteatoma from the bone in order to avoid tearing the sac, protection of fine structures • Monopole—Bipolar forceps • Plester suction tubes 5–9 Fr. • Suction cannulas, angular, 0.7–2 mm (adaptor with cut-off hole) • Cutting burrs: bone removal and identification of important landmarks • Diamond burrs: for more delicate procedures, like working near the facial nerve • Malleus nipper: removal of the malleus head • Hartmann ear forceps

CONCLUSION Cholesteatoma is still a dangerous disease that requires surgery to limit the possibility of dramatic or even life threatening complications. Although several decades have been passed since the first mastoidectomy under the microscope has been performed, the debate regarding the best surgical method still exists. It is obvious that when we perform extended CWD operations for limited diseases using an outside-inside approach, we create large cavities with likely postoperative problems. Sometimes, there is need for obliteration— flaps in order to make the cavity smaller, or even questionable reconstructive methods. On the other hand, CWU procedures are usually very lengthy, require significant experience and a second look operation and have a higher rate of residual-recurrent cholesteatoma. The proposed inside-outside approach includes endaural incision, an atticotomy, atticoantrostomy or limited mastoidectomy, according to different sizes and locations of cholesteatoma. It is a less invasive option, gives direct approach to the attic, usually creating small cavities with satisfactory long-term outcomes and without the need for second look.22,23 Therefore, it is an attractive alternative to the standard CWU and down procedures.

REFERENCES 1. De Foer B, Vercruysse JP, Bernaerts A, et al. The value of single-shot turbo spin-echo diffusion-weighted MR imaging in the detection of middle ear cholesteatoma. Neuroradiology. 2007;49(10):841-8.

The Surgical Management of Cholesteatoma 105 2. Dornhoffer JL. Retrograde mastoidectomy with canal wall reconstruction: a follow-up report. Otol Neurotol. 2004;25 (5):653-60. 3. Haynes DS. Perioperative antibiotics in chronic suppurative otitis media. Ear Nose Throat J. 2002;81(8 Suppl 1):13-5. 4. Bennett M, Warren F, Haynes D. Indications and technique in mastoidectomy. Otolaryngol Clin North Am. 2006;39 (6):1095-113. 5. Glasscock ME, Gulya AJ. Glasscock-Shambaugh Surgery of the Ear. 2002. 6. Nikolopoulos TP, Gerbesiotis P. Surgical management of cholesteatoma: the two main options and the third wayatticotomy/limited mastoidectomy. Int J Pediatr Otorhi­ nolaryngol. 2009;73(9):1222-7. 7. Palva T, Ramsay H. Treatment of labyrinthine fistula. Arch Otolaryngol Head Neck Surg. 1989;115(7):804-6. 8. Glasscock ME, Johnson GD, Poe DS. Surgical management of cholesteatoma in an only hearing ear. Otolaryngol Head Neck Surg. 1990;102(3):246-50. 9. Grewal DS, Hathiram BT, Saraiya SV. Canal wall down tympanomastoidectomy: the ‘on-disease’ approach for retraction pockets and cholesteatoma. J Laryngol Otol. 2007; 121(9):832-9. 10. Hulka GF, McElveen JT. A randomized, blinded study of canal wall up versus canal wall down mastoidectomy determining the differences in viewing middle ear anatomy and pathology. Am J Otol. 1998;19(5):574-8. 11. Dodson EE, Hashisaki GT, Hobgood TC, et al. Intact canal wall mastoidectomy with tympanoplasty for cholesteatoma in children. Laryngoscope. 1998;108(7):977-83.

12. Della Santina CC, Lee SC. Ceravital reconstruction of canal wall down mastoidectomy: long-term results. Arch Otola­ ryngol Head Neck Surg. 2006;132(6):617-23. 13. Beutner D, Stumpf R, Zahnert T, et al. [Long-term results following mastoid obliteration in canal wall down tympanomastoidectomy]. Laryngorhinootologie. 2007;86(12):861-6. 14. Gantz BJ, Wilkinson EP, Hansen MR. Canal wall reconstruction tympanomastoidectomy with mastoid obliteration. Laryngoscope. 2005;115(10):1734-40. 15. Godinho RA, Kamil SH, Lubianca JN, et al. Pediatric cholesteatoma: canal wall window alternative to canal wall down mastoidectomy. Otol Neurotol. 2005;26(3):466-71. 16. Hildmann H, Sudhoff H. Middle Ear Surgery. Germany: Springer; 2006.pp.:19-22,67-70. 17. Bleach N, Milford C, Hasselt VA. Operative Otorhi­nolary­ ngology. In: Birchall J (Ed.) Mastoid Surgery. Notti­ngham; 2001.pp.65-75. 18. Dornhoffer JL. Cartilage tympanoplasty. Otolaryngol Clin North Am. 2006;39(6):1161-76. 19. Vrabec JT. Delayed facial palsy after tympanomastoid surgery. Am J Otol. 1999;20(1):26-30. 20. Jackson CG. Antimicrobial prophylaxis in ear surgery. Laryngoscope. 1988;98(10):1116-23. 21. Smith JA, Danner CJ. Complications of chronic otitis media and cholesteatoma. Otolaryngol Clin North Am. 2006;39 (6):1237-55. 22. DeRowe A, Stein G, Fishman G, et al. Long-term outcome of atticotomy for cholesteatoma in children. Otol Neurotol. 2005;26(3):472-5. 23. Uyar Y, Oztürk K, Keles B, et al. Anterior atticoantrostomy for cholesteatoma surgery. Ann Otol Rhinol Laryngol. 2006; 115(2):150-5

CHAPTER

14

Transposed Canal Wall Tympanomastoidectomy Tuncay Ulug

INDICATIONS FOR THE SURGERY Transposed canal wall (TCW) tympanomastoidectomy is mainly used in the surgery of chronic otitis media with cholesteatoma.1,2 The main goals in the surgical management of chronic otitis media with cholesteatoma are eradication of the disease, prevention of a mastoidal bowl and restoration of the hearing mechanism. A variety of surgical approaches are currently used to achieve these goals. The main techniques used in cholesteatoma surgery are intact canal wall (ICW) and canal wall down (CWD) tympanomastoidectomy procedures, and their modifications (Figs 1 to 3). ICW techniques preserve the anatomy of the posterior canal wall, while CWD techniques create a mastoidal bowl.3,4 Other described techniques include retrograde tympanomastoidectomy procedures, obliteration techniques, posterior canal wall temporary removal techniques, and immediate or delayed posterior canal wall reconstruction techniques.3-7 A review of the literature reveals that each technique, evaluated taking into account the clinical findings, patients’ subjective complaints and the results of the

ossicular and hearing status according to the established rules,8,9 has its advantages and disadvantages. To overcome the problems encountered in cholesteatoma surgery, the described TCW technique was deve­ loped in Istanbul University1,2 (Fig. 4). TCW tympanomastoidectomy is a technique that provides improved exposure of the delicate anatomical structures and key areas without creating a mastoidal bowl. It is a one-stage, planned, outside-in technique resulting in a small anterior tympanomastoidectomy cavity, which is two times larger than a normal external auditory canal. In addition, it affords safe cholesteatoma removal, prevention of cholesteatoma recidivism and restoration of the hearing mechanism.

SPECIFIC PREOPERATIVE EVALUATION

Microscopic evaluation, audiologic assessment, high resolution computed tomography scans of the temporal bone and, in some cases, magnetic resonance imaging scans of the area are the main preoperative examinations/tests required.

Fig. 1: CWD—canal wall down tympanomastoidectomy

Fig. 2: ICW—intact canal wall tympanomastoidectomy

technique (view from anterior)

technique (view from anterior)

Transposed Canal Wall Tympanomastoidectomy 107

Fig. 3: M-ICW—conservatively-modified intact canal wall tympanomastoidectomy technique (view from anterior)

ANESTHETIC CONSIDERATIONS The procedure is performed under general anesthetic and local infiltration of 2% lidocaine hydrochloride with 1:100,000 epinephrine. No, or only finite hair removal, limited to the endaural or retroauricular area, is required. Patients are given perioperative intravenous antibiotics, ampicillin-sulbactam.

SURGICAL STEPS The technique is based on enlarging the external auditory canal extensively and exenteration of the anterior part of the tympanomastoid with an outside-in technique, so that a new canal is created with a superior wall at the middle cranial fossa dural plate, and the other walls transposed 2–3 mm posteriorly, inferiorly, and anteriorly.1,2 The TCW tympanomastoidectomy can be performed as an isolated technique, which is called TCW anterior tympanomastoidectomy, or as a combined technique—with a posterior mastoidectomy protecting the transposed posterior bony wall in between—which is called TCW combined tympanomastoidectomy. The procedures are carried out either through an endaural approach or a retroauricular approach (Fig. 5A). In all the approaches, the rest of the operation includes the same steps; neither the design of the meatal and tympanomeatal flaps nor the bony work is changed according to the approach. At the beginning of the operation grafts of temporo­ parietal fascia, temporal fascia and tragal or conchal cartilage are obtained. A classical tympanomeatal flap is elevated, followed by elevation of the laterally-based

Fig. 4: TCW—transposed canal wall tympanomastoidectomy technique; isolated anterior or combined (view from anterior)

posterior and anterior meatal flaps, which are preserved carefully during the drilling (Fig. 5B). In exceptional cases of sufficient anterior exposure, the anterior meatal skin may be left in place. The initial steps in drilling are superior and posterior canal widening (Figs 5C and D) followed by inferior and anterior widening (Figs 5E and F). This is a planned outside-in extensive drilling, which comprises of not only enlargement of the external auditory canal but also partial exenteration of the anterior part of the tympanic and mastoid bones. In this way, the new superior canal wall is recreated regularly at the middle cranial fossa dural plate, and the other walls are transposed a couple of millimeters posteriorly, inferiorly and anteriorly (Fig. 5F). If maximum exposure is required, a mastoid facial nerve skeletonization posteriorly, jugular bulb skeletonization inferiorly, and temporomandibular joint periosteum skeletonization anteriorly may be performed through this anterior main route. When the cholesteatoma is limited posteriorly to the aditus, all the cholesteatoma is removed through this anterior isolated tympanomastoidectomy procedure (TCW anterior tympanomastoidectomy), and when the choles­ teatoma is beyond the limits of the aditus, e.g. reaching antrum, a posterior mastoidectomy is added to the procedure, protecting the transposed posterior canal wall intact (TCW combined tympanomastoidectomy) (Fig. 4). In this case, the cholesteatoma is delivered from the antrum through the aditus anteriorly into the attic. The rest of the cholesteatoma is dissected through the anterior access. In either case, all the delicate structures and key areas, meaning the attic, aditus, horizontal semicircular canal, facial recess, tympanic facial nerve, sinus tympani,

108 Otology and Lateral Skull Base the ossicles, oval and round window, are explored and cleared off choles­ teatoma through the anterior access (Figs 5G and H). According to the finding of the ossicles, they are denuded and left intact or various ossiculoplasty techniques are performed (Fig. 5I). After total cholesteatoma removal and ossicular reconstruction, a piece of cartilage with perichondrium is used to partially fill the anterior mastoidal tegmen adjacent to the middle cranial fossa dural plate. The attic is also reconstructed using the same or another piece of cartilage and temporal fascia (Figs 5J and K). In sinus cholesteatoma cases, the posterior tympanic membrane area and in tensa cholesteatoma cases, the whole tympanic membrane are also reconstructed using cartilage and temporal fascia. The rest of the temporal fascia and the temporoparietal fascia are used to cover any bare bony areas. The laterally-based posterior and anterior meatal flaps are put on the grafts lining the cavity. If required, the incisions of the posterior meatal flap are slightly extended laterally to fit the flap better to the posterior wall of the cavity. The small cavity is packed with several pieces of gelfoam. In cases of combined TCW, any additional procedure is applied to the posterior mastoidectomy cavity. The wound incision is closed with a few subcutaneous and cutaneous sutures and dressed with bandage. Meatoplasty is not required (Fig. 5L). No drain is used. The bandage is removed and the patient is discharged the day after surgery.

Features TCW tympanomastoidectomy provides improved exposure of the delicate anatomical structures and key areas without creating a mastoidal bowl.1,2 Before the 1950s, the only surgery that was popularly used for chronic suppurative otitis media was modified radical mastoidectomy, i.e. CWD tympanomastoidectomy.10,11 In the late 1950s, combined approach tympanoplasty, i.e. ICW, was described and gained popularity among otologists.12,13 In CWD techniques, removal of the canal wall improves exposure and affords complete removal of cholesteatoma. However, the postoperative healing time is long; the resulting large cavity is prone to bowl infections and retention cholesteatoma, and do require periodic cleansing.5,6 The retrograde modification of this technique, e.g. beginning with an atticotomy and enlarging the cavity with an inside-out procedure, also results in most instances in a large atticoantrotomy cavity. Preservation of the canal wall in ICW techniques maintains the normal anatomy of the external auditory canal, shortens the postoperative healing time and avoids cavity problems. However, surgical exposure of the key areas in the attic and mesotympanum is limited, leading to higher

residual cholesteatoma rates; and the preservation of the posterior canal wall in its natural position is prone to retraction, leading to higher recurrence rates.4,7 To resolve the disadvantages and combine the advantages of ICW and CWD tympanomastoidectomy, many techniques have been proposed. Mastoid ­ obliteration techniques including Palva flap and inferior-based musculoperiosteal flap have long been used to decrease the size of the cavity after CWD procedures.4 The longterm follow-up of these techniques revealed that following shrinkage of soft tissue, the cavity problems partially reappeared. Ceramics, hydroxyapatite granules, demineral­ ized bone matrix, bone paste and titanium have been used to obliterate the cavity or to reconstruct the posterior canal wall. The main drawback of these techniques is a higher infection rate.4,14 Contrarily, postoperative infection is not a concern in TCW tympanomastoidectomy. Temporary removal of the posterior canal wall and replacement at the end of the operation has also been used by different authors. This technique affords complete removal of cholesteatoma and reconstruction near normal anatomy.3,4,7 The major drawback of this technique is also that the postoperative infection rate is higher than in classical techniques and postoperative infections may result in partial destruction of the reconstructed posterior canal wall. The other minor drawback is the possibility of formation of recurrent retraction pockets.4 For CWD procedures, delayed reconstruction techniques of the posterior canal wall with cortical bone or ceravital have also been described.5,6 Additionally, to overcome the disadvantages of ICW and CWD, modified combined approach tympanoplasty and combined approach tympanoplasty with anterior atticotympanotomy have been described.15,16 The main contribution of these techniques to classical ICW have been better exposure of the attic through transmeatal atticotomy following the recommendations of Lempert many decades ago.11,17 The common feature of these approaches, which are used in selective indications, are that the external auditory canal is only enlarged superiorly towards middle cranial fossa like in atticotomy or in atticoaditotomy and left untouched posteriorly, inferiorly and anteriorly, meaning the posterior wall is in the same position like in ICW. In these approaches, the exposure in the retrotympanum, facial recess and hypotympanum is afforded with exenteration of bone only around posterior tympanic annulus and therefore the exposure in these areas is limited. The proposed technique, TCW tympanomastoidec­ tomy, has been designed to recreate a new, relatively large, external auditory canal having a superior wall at the middle cranial fossa dural plate and the other three

Transposed Canal Wall Tympanomastoidectomy 109

A

B

C

D

E

F

G

H

I

J

K

L

Figs 5A to L: Operation steps; TCW anterior tympanomastoidectomy (endaural; tensa cholesteatoma; Type III reconstruction).

(EI: Endaural incision; SH: Spine of Henle; AMF: Anterior meatal flap; PMF: Posterior meatal flap; MDP: Middle cranial fossa dural plate; PD: Posterior drilling; PTW: Posteriorly transposed wall; ID: Inferior drilling; ITW: Inferiorly transposed wall; ATW: Anteriorly transposed wall; CHO: Cholesteatoma; AD: Aditus; SS: Stapes superstructure; TSC: Tympanic sinus cholesteatoma; ESM: Exposed stapedial muscle; SFN: Skeletonized mastoidal facial nerve; TTC: Tympanic membrane reconstruction with tragal cartilage; STC: Superior wall reconstruction with tragal cartilage; TF: Temporal fascia; MR: Merocel)

walls transposed 2–3 mm posteriorly, inferiorly and anteriorly.1,2 The procedure has the primary intention of creating a new canal at an exact location and exposure of the cholesteatoma is the separate, second step of the procedure. Following this planned, outside-in extensive drilling and creating an anterior small tympanomastoid cavity, the cholesteatoma exposure and removal begins. The

goal of the technique is to remove all the cholesteatoma through the anterior approach. A posterior mastoidectomy is added, only if the cholesteatoma extends beyond the posterior entrance of the aditus or if extensive hypertrophic mucosal disease with granulations and polyps exists. Because the posterior wall of this new canal or cavity is in ideal position, there is no need to change the

110 Otology and Lateral Skull Base operation to a CWD procedure, which is often performed by inexperienced surgeons in difficult cases during ICW operations. The only restriction of TCW tympanomastoidectomy is an extensively destroyed or thinned posterosuperior wall with cholesteatoma which prevents skeletonization of the anterior antrum wall. In TCW tympanomastoidectomy, cholesteatoma resection is safe as with a CWD procedure and because of partial exteriorization, the recurrence rate is also low. To prevent retraction pockets, the attic is reconstructed in all cases with cartilage and the posterosuperior quadrant is also supported with cartilage according to the needs of the case. In this technique, the retraction and choles­teatoma recurrence risk is reduced because of the exteriorized shape of the cavity and usage of the cartilage for tympanic and attic reconstruction. Recidivism would also be detected early in TCW tympanomastoidectomy, because they would be expected to occur in the anterior cavity; through office inspection, it is possible to notice recidivism early on and possibly treat it with an office procedure. The reconstruction in TCW is nearly as good as in the ICW technique. The resulting cavity which has the shape of a cut cone is only two times larger than a normal external auditory canal. The intact bony walls prevent bowl problems and provide the best protection against invasion and extension of cholesteatoma in cases of recidivism. There is no need for a classical meatoplasty. The healing time of the new canal is comparable to that of a canalplasty because, nearly, all the bear bony areas are covered with some soft tissue, i.e. meatal flaps, cartilage or fascia. Cavity problems do not exist because of the limited volume of the cavity. The position of the pinna do not change in any case, which may be a problem in conventional and in muscle obliterated CWD procedures. The exposure in TCW technique not only facilitates cholesteatoma removal, but also affords the surgeon the potential to preserve the normal middle ear hearing mechanism. Complete exposure of all the ossicles through the same route enables, in some cases, the integrity of the ossicular chain to be protected, which results in the best hearing condition. In general, the hearing results are comparable to ICW tympanomastoidectomy; the support points around the ossicles and new tympanic membrane are sufficient for good hearing restoration.

COMPLICATIONS The TCW tympanomastoidectomy is a safe technique. This technique provides improved intraoperative exposure of the key areas without creating a mastoid bowl, reduces the incidence of recidivism, and allows for hearing restoration, while preventing major complications.

A review of a published study of the author would help in analyzing the advantages and disadvantages of the technique.1 A prospective, nonrandomized study of consecutive patients undergoing TCW tympanomastoidectomy was performed at the Istanbul Medical Faculty of Istanbul University. The setting was tertiary referral center and academic practice in otology. The study comprised of 11 procedures—8 adults and 3 children with an age range of 12–66 years—chosen randomly to be operated with the TCW technique. All the operations were performed by the author. Cholesteatoma was limited in the tympanic cavity in two cases, localized or extended into the attic in two cases, extended into aditus in four cases, and into antrum in three cases. The soft tissue approach was endaural in eight cases, retroauricular in two cases and retroauricular with endaural relaxation incision in one case. In eight patients, the bony access was limited to the anterior part, i.e. TCW anterior tympanomastoidectomy was performed; in three patients—with antrum extension of cholesteatoma—the anterior as well as the posterior bony access was used, i.e. TCW combined tympanomastoidectomy was performed. Different types of ossiculoplasty were used to reconstruct the hearing mechanism. In two cases with intact but partially eroded ossicles, the chain was left intact. In three cases, some type of interposition graft was used. In one case, total ossicular replacement prosthesis (TORP) and in one case, incus columella between malleus handle and stapes footplate was preferred. Three cases were reconstructed as Type III tympanoplasty and one case, with total destruction of all three ossicles, was planned for a second stage ossiculoplasty. The mean air-bone gap, according to the four pure-tone air and bone conduction threshold averages, were found to be 30.18 dB HL preoperatively and 20.09 dB HL postoperatively. The mean gain in the air-bone gap was 10.09 dB HL. The postoperative hearing status at the final evaluation was better than at the preoperative hearing status in eight cases; did not change in three cases. In two of these cases, the hearing was good preoperatively as well as postoperatively and in the third case, because of extensive destruction, the hearing restoration was left for a second stage without any primary reconstruction. Temporary postoperative complications were encountered in two cases. One patient had postoperative cavity infection in the early postoperative period, which resolved after a short-period local therapy. The other patient had granulation problems, also in the early postoperative period, in the medial part of the cavity close to the new tympanic membrane, which resolved after office excisions of the granulations. As permanent complication, only one case with a classical Type III reconstruction, i.e. without

Transposed Canal Wall Tympanomastoidectomy 111 posterosuperior cartilage support, showed slight retraction in the posterior mesotympanum, however, there was no need for further surgery. All of the 11 ears maintained a small and dry anterior tympanomastoidectomy cavity which was two times larger than a normal external auditory canal. There were no major complications. During the follow-up with a mean 20 months, there was no residual or recurrent cholesteatoma, tympanic membrane perforation, permanent otorrhea or meatal stenosis. The position of the pinna did not change in any case and there was no need for water restriction in any case.

SPECIAL INSTRUMENTS USED FOR THE SURGERY

The required instruments are microscope, drill system and ear microsurgery instruments. The author routinely uses “Ulug double-sided ear microsurgery instruments” for tympanoplasty-mastoidectomy and other otologic procedures. During the operation, instruments with different tips, such as right and left curved microdissectors, are needed alternately. The double-sided microsurgery instruments, designed by the author as a set, provide both speed and convenience; only one maneuver of the fingers is required to rotate the instrument, thus enabling usage of the appropriate tip. “Ulug double-sided ear microsurgery instruments” are produced by Karl Storz, Tuttlingen, Germany.

OTHER TREATMENT OPTIONS

AVAILABLE FOR THE SAME CONDITION

A variety of surgical approaches are currently used to eradicate cholesteatomas and restore the hearing mechanism. They mainly include ICW and CWD tympanomastoidectomy techniques, and their modifications. ICW techniques preserve the anatomy of the posterior canal wall and eliminate the bowl problems; however, the recidivism rate is higher than with CWD techniques. CWD techniques reduce the recidivism rate, however, they create a mastoidal bowl needing periodic cleansing.3,4 To eliminate the disadvantages of both categories, different techniques have been proposed—retrograde tympanomastoidectomy procedures, obliteration techniques, posterior canal wall temporary removal techniques, and immediate or delayed posterior canal wall reconstruction techniques using various materials.3-7 The described technique, TCW tympanomastoidectomy,

has been designed to increase the exposure in the critical anterior part of the temporal bone and remove cholesteatoma safely, while preventing a large mastoidal bowl.

REFERENCES 1. Ulug T. Transposed canal wall tympanomastoidectomy. Int Adv Otol. 2010;6:131-40. 2. Ulug T. Atlas of Temporal Bone Surgery. Stuttgart: Thieme; 2010. 3. McElveen JT Jr, Chung AT. Reversible canal wall down mastoidectomy for acquired cholesteatomas: preliminary results. Laryngoscope. 2003;113(6):1027-33. 4. Gantz BJ, Wilkinson EP, Hansen MR. Canal wall reconstruction tympanomastoidectomy with mastoid obliteration. Laryngoscope. 2005;115(10):1734-40. 5. Sasaki Y, Iino Y, Suzuki J. Posterior canal wall reconstruction tympanoplasty for operated ears with open mastoid. Acta Otolaryngol. 2002;122(3):249-54. 6. Della Santina CC, Lee SC. Ceravital reconstruction of canal wall down mastoidectomy: long-term results. Arch Otolaryngol Head Neck Surg. 2006;132(6):617-23. 7. Babighian G. Posterior and attic wall osteoplasty: hearing results and recurrence rates in cholesteatoma. Otol Neurotol. 2002;23(1):14-7. 8. Austin DF. Ossicular reconstruction. Otolaryngol Clin North Am. 1972;5(1):145-60. 9. Committee on Hearing and Equilibrium guidelines for the evaluation of results of treatment of conductive hearing loss. American Academy of Otolaryngology—Head and Neck Surgery Foundation, Inc. Otolaryngol Head Neck Surg. 1995;113(3):186-7. 10. Bondy G. Totalaufmeisselung mit Erhaltung von Trommelfell und Gehörknöchelchen. Monatschrift für Ohrenhei­ lkunde und Laryngo-Rhinologie. 1910;44:15-23. 11. Lempert J. Lempert endaural subcortical mastoidotympanectomy for the cure of chronic persistent suppurative otitis media. Arch Otolaryngol. 1949;49(1):20-35. 12. Jansen C. The combined approach for tympanoplasty (report on 10 years’ experience). J Laryngol Otol. 1968;82(9):779-93. 13. Sheehy JL, Patterson ME. Intact canal wall tympanoplasty with mastoidectomy. A review of eight years’ experience. Laryngoscope. 1967;77(8):1502-42. 14. Black B. Mastoidectomy elimination: obliterate, reconstruct, or ablate? Am J Otol. 1998;19(5):551-7. 15. Tos M. Modification of combined-approach tympano­plasty in attic cholesteatoma. Arch Otolaryngol. 1982;108 (12): 772-8. 16. Farrior JB. The canal wall in tympanoplasty and mastoidectomy. Arch Otolaryngol. 1969;90(6):706-14. 17. Lillie HI, Simonton KM. The mastoid incision; endaural or postauricular? Surg Clin North Am. 1949;29(4):1093-6.

CHAPTER

15

Inside-Out Mastoidectomy Amol Patil, Sonal Modi, Madhuri Mehta, Narayan Jayashankar, KP Morwani

PHILOSOPHY OF INSIDE-OUT MASTOIDECTOMY

We all know that the cholesteatoma starts in attic and nowadays more and more patients of cholesteatoma present with limited disease restricted to the attic with minimal extension (30–60%). It is not logical to expose and drill the healthy mastoid cortex in order to reach the disease in the attic, hence a rational approach to reach disease is to follow it from inside, i.e. from attic and follow it wherever it extends. The authors have redefined and redesigned this approach to reach every nook and corner of mastoid bone and if required beyond boundary of mastoid bone, to every anatomical structure in temporal bone and beyond it. The aim of the surgery should not only be to make ear safe and dry but to try and improve hearing level in as many cases as possible in first sitting. The authors believe in avoiding creating a cavity when disease is restricted to attic antrum and marginally beyond. In case of extensive disease, the authors like to reduce size of cavity by partial or subtotal obliteration. The principle to be followed before obliteration is complete eradication of cholesteatoma along with exenteration of all the cells and endothelium deeper to cholesteatoma. The idea is to give small, circular, self-cleansing cavity, thus avoiding doctor dependence for rest of life. By reducing size of cavity, the authors avoid performing disfiguring meatoconchoplasty. The authors like to perform wide meatoplasty by drilling floor of bony canal and excising floor cartilage; they do not like to excise conchal cartilage as far as possible. Inside-out mastoidectomy for cholesteatoma is the most rational approach. As mentioned earlier, cholesteatoma starts as an attic disease. With early detection, fair number of the cases of cholesteatoma will be eradicated by atticotomy or atticoantrostomy, followed by reconstruction of outer attic wall or atticoantral wall, thus avoiding the creation of a cavity totally. In certain cases of limited attic cholesteatoma, the authors still perform simple mastoidectomy to confirm or establish ventilation pathways for mastoid air-cell system. These situations

are grossly edematous mucosa of promontory, excessive granulation tissue in middle ear or attic, fair amount of glue draining from aditus, adhesive or tympanosclerotic pathology. Till 5–6 decades back, certain centers did not believe in putting temporalis fascia graft for fear of leaving buried epithelium. The same applies for partial or complete obliteration of cavity in the last 2–3 decades. In this era of better training with improved optics of microscopes, better drill machines, different sizes and type of burrs and fine and delicate instruments, it is possible to eradicate the cholesteatoma from each and every corner of the mastoid bone. Outside-in technique is still being performed by a fair number of centers, the most important aspect being flaw in training. Most temporal bone dissection workshops teach the anatomy of temporal bone from outside in. Thus, the inside-out approach is generally alien to majority of ENT surgeons. The most common location of residual cholesteatoma in middle ear cleft is anterior epitympanum and tympanic recess. As far as anterior epitympanum is concerned, inside-out mastoidectomy starts with an atticotomy which helps to follow the disease in continuity in entire attic, thus reducing incidence of residual epithelium. The second common area of residual cholesteatoma in middle ear cleft is tympanic recess. Literature has adequately emphasized lowering of facial ridge but thinning of facial ridge is key to adequate access to this area; thinning of facial ridge involves drilling of bony annulus anterior to fallopian canal in its vertical course. Anatomy of temporal bone from outside-in or insideout is same. Surgeons interested in performing inside-out mastoidectomy for cholesteatoma should be well versed with the inside-out anatomy of the temporal bone. Cholesteatoma extending beyond mastoid antrum is managed by canal wall down technique; the bone dissection proceeds as per inside-out technique. The outer cortical bone and mastoid cells, lateral, superior and inferior to cholesteatoma sac, are drilled out, sac exteriorized completely and removed in continuity under higher magnification; residual mucosal cells of mastoid are drilled out completely, any uneven surface in depth is saucerized

Inside-Out Mastoidectomy 113 whenever possible. Facial ridge is lowered and thinned to align with depth of cavity, the tegmen, and sigmoid sinus plate; presigmoid dural plate is smoothened and polished completely; anterior attic wall and anterior canal wall are aligned, floor of canal is drilled to match floor of mastoid cavity. Necessary partial or subtotal obliteration of cavity is performed along with ossiculoplasty and reconstruction of drum. In cases of granulation tissue disease in attic extending to antrum or mastoid air-cell system, the authors do not recommend canal wall down technique. Even when granulation tissue pathology extends to aditus area, they recommend extended mastoidectomy from outside in after atticotomy when there is no evidence of cholesteatoma in attic. Even in cases of extensive granulation tissue pathology eroding part of posterior canal wall, the authors will reconstruct posterior canal wall after clearing granulation tissue from attic and mastoid air-cell system. This granulation tissue should be sent for histopathology examination to exclude Koch’s or any other pathology responsible for osteolytic activity like malignancy. In pediatric age group, granulation tissue pathology very often leads to mastoid abscess and intracranial extension and complications. Cases of recurrent cholesteatoma or persistently discharging cavity are dealt with by complete clearance of cholesteatoma and granulation tissue or mucosa and partial or complete obliteration of mastoid cavity. At times, inadequate bone work is performed by the first surgeon. In these cases, the authors perform necessary bone work to expose the cholesteatoma and remove it completely. Otogenic intracranial abscess, which are most often in continuity with some part of temporal bone [confirmed with computed tomography (CT) scan of temporal bone, bone window], are always drained by transmastoid approach. The access to disease will be inside out or outside in depending on extent of disease. The authors will always perform necessary tympanoplasty or ossiculoplasty in the same sitting, advantage being clearance of both pathology in the same sitting and reconstruction of dural or bony defect at the same time. Cases of recurrent cholesteatoma, associated with brain herniation and recurrent intracranial complication, are treated by surgical eradication of disease, removal of all epithelium and mucosa in the mastoid air cell system followed by cul de sac closure.

perform outside-in mastoidectomy, where they again stick to principle of following the disease.

PREOPERATIVE EVALUATION AND

ANESTHETIC CONSIDERATIONS ARE THE SAME AS FOR ANY ROUTINE EAR SURGERY

The authors do not perform postaural shaving.

SURGICAL STEPS The procedure is performed under suitable anesthesia, though the authors perform most of the cases under local anesthesia with anesthetist on standby.

Incision Postaural skin incision, which is placed 4–5 mm behind the postaural groove, is performed (Fig. 1). The superior limb of the incision extends to the point above the helix to obtain proper exposure of the anterior canal wall and attic. The inferior limb extends up to the mastoid tip or up to the horizontal plane just below the floor of the external auditory canal (EAC), so as to have better access to the anteroinferior canal wall. This incision is inclusive of both skin and subcutaneous tissue. The posterior margin of skin and subcutaneous tissue are mobilized for about 2–3 mm to facilitate the application of mastoid retractor, and help to close the incision in a single layer. Temporalis fascia graft of size approximately 3 cm by 3 cm can be harvested at this stage of the surgery. Generally, the graft is harvested after mobilization of the skin flaps and

INDICATIONS FOR INSIDE-OUT SURGERY

In every case, the authors perform inside-out technique. However, only in cases with mastoid fistula, the authors

Fig. 1: Postaural incision of 4–5 mm posterior to groove with cross hatching (right ear)

114 Otology and Lateral Skull Base the same can be harvested after clearance of disease. A large graft is generally harvested, as it shrinks approximately by one-third in its dimensions after harvesting (Fig. 2).

Musculoperiosteal Incision A musculoperiosteal incision is performed in a C-shaped manner, in three-fourth circumference, which starts from the root of the zygoma superiorly, lateral to the bony margin of the EAC (Figs 3A and B). This is ensured by placing the finger through the EAC, and curve along posterior and then inferior bony margin. Additional horizontal incision is performed between temporalis muscle and postaural muscle; postaural muscle mobilized posteroinferiorly. External auditory canal skin is then elevated in threefourth circumference up to annulus and at this level, the

skin is incised from drum and then mobilized laterally, thus exposing the bony canal superiorly, posteriorly and inferiorly (Fig. 4). Sharp dissection needs to be made in the region of tympanomastoid and squamotympanic suture line. In cases of anterior canal wall bulge, the canal skin is elevated in complete circumference and is delivered outwards (laterally towards the concha) (Fig. 5). The floor cartilage is excised either at this stage or after performing necessary bony work. This is performed in every situation of inside-out mastoidectomy. The most important advantage of it is that it helps in widening the canal inferiorly. The further advantage of excising floor cartilage is that it provides additional epithelium towards the annulus or towards the floor of the cavity (Fig. 6). The bony meatoplasty is performed with the help of cutting burr, drilling the healthy outer bony canal wall in three-fourth or complete circumference to visualize bony annulus. A few drops of saline are used to prevent spreading of bone dust, and bone dust is collected from healthy areas of outer half of EAC. This healthy bone dust is collected to be used later for obliteration of sockets or the cavity itself if required (Figs 7 to 9).

Atticotomy

Fig. 2: Harvesting of temporalis fascia graft (right ear)

A

Drilling is continued from superior canal wall toward attic in inside-out manner, the principle is to follow the cholesteatoma. Cholesteatoma at times can be restricted to anterior attic, posterior attic or it may invade complete attic. Rarely, ossicular chain may be completely intact and cholesteatoma is restricted lateral to ossicle. In this situation, after exposing and excising sac in complete

B Figs 3A and B: Musculoperiosteal incision in three-fourth circumference and between temporalis muscle and postaural muscle (right ear)

Inside-Out Mastoidectomy 115

Fig. 4: Elevation of canal skin in three-fourth circumference (right ear)

Fig. 5: Elevation of canal skin laterally in complete circumference in case of anterior canal bulge (left ear)

Fig. 6: Harvesting floor cartilage after

Fig. 7: Widening of canal and collection

mastoidectomy (left ear)

of bone dust (left ear)

Fig. 8: Collection of bone dust

Fig. 9: Bony meatoplasty—widening of canal in threefourth circumference with partial atticotomy (right ear)

116 Otology and Lateral Skull Base dimension, defect created by drilling of the outer attic wall is reconstructed by placing the piece of cartilage with intact perichondrium. Drilling should be continued in attic to exteriorize the cholesteatoma sac in complete circumference. If cholesteatoma sac is extending up to attic only, the sac is removed in continuity and outer attic wall defect created is reconstructed with piece of cartilage as described earlier. While reconstructing the attic defect, the placement of cartilage should be precise; care must be taken to maintain the ventilation pathway from middle ear (Figs 10A to C). As mentioned earlier, in case of limited cholesteatoma restricted to attic, the authors do perform simple mastoidectomy to confirm patency of ventilation pathway if there is extensive granulation tissue in attic, grossly hypertrophic mucosa on promontory, glue in middle ear or attic, tympanoslerotic plaques around ossicle or plastered drum. In case of cholesteatoma extending to aditus, partial or complete antrum; in these situations, an atticotomy or

A

atticoantrostomy is performed to remove the cholesteatoma sac in toto and the defect is reconstructed with cartilage as mentioned earlier. Temporalis fascia graft is placed using underlay technique, placing the graft over bony annulus and the cartilage piece for reconstruction of outer attic wall (Figs 11A to D).

Canal Wall Down Facial Nerve As far as damage to facial nerve is concerned, there is not even a slightest chance of damaging facial nerve by drilling outer atticoantral wall. Fallopian canal is protected by presence of incus and partly by head of malleus, as it lies deeper to these structures and drilling is lateral to these ossicles. In case of erosion of body of incus, this space is occupied by cholesteatoma flakes and/or granulation tissue. Facial nerve can be damaged in floor of attic, deeper to sac if the fallopian canal is eroded by pathology

B

Figs 10A to C: Atticotomy with ossiculoplasty with attic

C

reconstruction (cartilage) for limited attic cholesteatoma (left ear)

Inside-Out Mastoidectomy 117

A

B

C

D Figs 11A to D: Atticoantrostomy followed by ossiculoplasty with attic reconstruction (cartilage) for atticoantral cholesteatoma (right ear)

or if there is macro or micro dehiscence of it; this can occur while dissecting sac from fallopian canal. To avoid this, sac should be elevated under high magnification in continuity and by blunt instrument, and use of small suction cannula. Any soft tissue, few millimeters away from normal course of facial nerve in any direction, should be handled cautiously till the surgeon has oriented himself to anatomy of fallopian canal. The damage to fallopian canal can occur while lowering or thinning the facial ridge and that can be avoided by following the principle described in the literature. Cholesteatoma extending beyond antrum is generally managed by canal wall down technique; drilling is carried out lateral to sac following the sac till the sac is visualized in complete circumference, which could be up to sinodural angle, mastoid air-cell system or up to mastoid tip (Figs 12A to H). Always remove sac in continuity,

completely under high magnification. Caution is to be taken while elevating the sac from lateral semicircular canal, fallopian canal and stapes footplate area. After excising the cholesteatoma sac completely, all accessible cells of mastoid air-cell system are drilled out and depth of cavity is saucerized totally. Tegmen is smoothened in complete depth; the anterior attic wall is aligned to anterior canal wall; sinodural angle is smoothened; sinus plate and presigmoid dural plate are polished; the entire cells lateral to SSC drilled; mastoid tip is smoothened, and edges of cavity are saucerized. The floor of canal has to be aligned with floor of cavity by drilling floor of canal or filling mastoid tip with bone dust or excising the mastoid tip. Any bony socket in depth are overfilled with bone dust, cartilage or deeper part of postaural muscle with

118 Otology and Lateral Skull Base

A

B

C

D

E

F Figs 12A to F

Inside-Out Mastoidectomy 119

G

H Figs 12A to H: Attic cholesteatoma extending beyond antrum—canal wall down mastoidectomy (left ear) (FR: Facial ridge)

Fig. 13: Obliteration of bony sockets with

Fig. 14: Obliteration of cavity with cartilage and bone dust

bone dust (left ear)

to be filled below it (right ear)

periosteum (Figs 13 and 14). Temporalis fascia graft underlay technique is most commonly performed; fascia should be placed over the bony annulus.

2. Loss of incus with intact suprastructure of stapes: Piece of cartilage with perichondrium is directly placed over stapes head. In cases where residual pars tensa is very thin or most of it is missing, the authors would like to place rectangular cartilage piece from head of stapes to inferior annulus to maintain depth of middle ear cleft and prevent medialization of neotympanum (Fig. 17). 3. Loss of incus with loss of supra structure of stapes: Piece of boomerang shaped cartilage from foot plate of stapes to anteroinferior part of annulus (Figs 18 and 19). The authors perform ossiculoplasty and myringoplasty even in cases of otogenic intracranial complication including extradural, perisinus, subdural and brain abscess.

Ossiculoplasty The necessary ossiculoplasty depending upon residual ossicle available is performed. The authors will describe three common scenarios and necessary reconstruction technique. 1. Loss of lenticular process with or without loss of part of long process of incus: In this situation, the authors take piece of cartilage which is placed over head of stapes under the residual incus (Figs 15 and 16).

120 Otology and Lateral Skull Base

Fig. 15: Necrosis of lenticular process of incus (right ear)

Fig. 16: Cartilage ossiculoplasty from long process to stapes head (right ear)

Fig. 17: Necrosis of long process of incus—cartilage ossi­

Fig. 18: Only mobile footplate present (left ear)

culoplasty from remnant of long process to stapes head also in contact with malleus head (right ear)

They perform ossiculoplasty, even in patient with sensorineural loss and dead ear as they like to create middle ear space, maintain ventilation pathway. This is to prevent future medialization of drum which could lead to indrawing of epithelium in tympanic recess leading to formation of cholesteatoma.

Partial Obliteration of Cavity Small and medium sized cavities are reduced in diameter and depth by using bone dust, cartilage or the muscle with periosteum. This is covered by temporalis fascia graft. Large cavities, cavities extending inferiorly are managed by excising the mastoid tip as mentioned earlier;

if cavity is too large posteroinferiorly, then the postaural muscle pedicled flap can be utilized to reduce the size in this area; in case of extensively large cavity, one can utilize large temporalis muscle flaps.

Management of Exposed Dura Tegmen can be eroded by the disease or damaged by surgeon at times. Small-sized tegmen defects can be ignored; tegmen defects of more than 1.5–2 cm are to be reinforced by placing a piece of cartilage or bone piece. This is to prevent future herniation of brain into the mastoid cavity.

Inside-Out Mastoidectomy 121 Meatoplasty Meatoplasty is performed in cases of limited cholesteatoma, managed by atticotomy or atticoantrostomy. Canal skin, mobilized in three-fourth circumference, is further mobilized upwards in the same plane up to chonchal cartilage. In the inferior part, floor cartilage is excised, the artery forceps placed through meatal opening coming out from lower end of canal flap; the skin of posterior canal wall is incised vertically up to chonchal cartilage and at

this level, two horizontal incisions are performed to create upper and lower skin flaps; the upper flap is sutured to superficial temporal muscle and lower flap is sutured to subcutaneous tissue to margin of inferior meatus and posteroinferiorly to postaural muscle (Figs 20 to 22). This suturing is performed after suturing temporalis muscle with postaural muscle. Meatoplasty should be wide enough so that one should be able to insert index finger; the junior surgeon should be performing wider meatoplasty and thumb could be inserted (Fig. 23). To achieve this, you may have to excise part of chonchal cartilage. Size of the meatoplasty should be proportionate to size of cavity. Since the authors do not believe in giving disfiguring meatoplasty for abnormally large cavities, they always prefer to reduce size of cavity.

Closure

of stapes to anteroinferior annulus (left ear)

Before performing meatoplasty, after placing graft and performing necessary ossiculoplasty, the authors place small piece of gel foam to stabilize the graft or to push back annulus if mobilized earlier. They use gel foam soaked in blood from the operative site. The canal or cavity skin is placed back before packing the canal or cavity only with gel foam. Postaural wound is sutured in layers preferably with subcuticular technique (Fig. 24). Routine mastoid dressing is applied which is removed after 24 hours. Patient is discharged same day evening or next day morning.

Fig. 20: Meatoplasty vertical incision along canal skin (left ear)

Fig. 21: Meatoplasty horizontal extension of incision and

Fig. 19: Boomerang cartilage ossiculoplasty from footplate

creation of superior and inferior flaps (left ear)

122 Otology and Lateral Skull Base

Fig. 22: Meatoplasty superior flap sutured to temporalis muscle and inferior flap sutured to postaural muscle (left ear)

Fig. 23: Meatoplasty—width confirmed by placing index finger (left ear)

ADVANTAGES OF INSIDE-OUT TECHNIQUE

Fig. 24: Closure of skin incision with subcuticular suturing (left ear)

• Following the disease directly from the attic to wherever it extends. • Drilling of the outer attic wall from inside will help in removing the cholesteatoma in continuity completely without the disadvantage of unnecessary bone work beyond the boundaries of the cholesteatoma. • Avoidance of cavity whenever possible. • No second look surgery required since outer attic wall is drilled. This prevents residual epithelium from being left under the lateral attic wall. • In cases requiring canal wall down technique, obliteration of bony sockets and partial obliteration of cavity lends smoothness to depth of cavity. • Aligning the floor of canal to floor of cavity, anterior canal wall to anterior attic wall, polishing the complete tegmen and sinus plate, along with obliteration of sinodural depth leads to an ideal circular cavity.

Inside-Out Mastoidectomy 123

BIBLIOGRAPHY 1. De Aquino JEAP, Filho NAC, de Aquino JNP. Total reconstruction after canal wall down mastoidectomy with posterior wall of external auditory canal and allograft ossicular ear drum-Long term observation. Int Arch Otorhinolaryngol. 2007;11:116-27. 2. Facek RR Ear Surgery. Berlin, Heidelberg: Springer-Verlag; 2008. pp. 55-60. 3. Gulya AJ, Minor LB, Poe DS. Glasscock-Shambaugh Surgery of the Ear, 6th edition. 2010. pp. 527-28. 4. Marcos V Goycoolea. Guidelines for Dissection of Temporal Bone. [online] Available from http://sigmamax.tripod.com/ ent/paparella/pap0213.pdf. 5. Medscape Reference. Cholesteatome Treatment & Manage­ ment. [online] Available from http://emedicine.medscape. com/article/860080-treatment. 6. Modified Radical Mastoidectomy—The Inside-out technique”. [online] Lookfordiagnosis website. Available from http://www.lookfordiagnosis.com/videos.php?title=Mo

dified+Radical+Mastoidectomy+%22+The+Inside+out+tec hnique%22&content=Modified+radical+mastoidectomy+ +in+attic+cholesteatoma.+Cholesteatoma+sac+in+the+mi ddle+ear+can+be+clearly+seen.+Incus+and+suprastructur e+of+...&lang=1. 7. Pensak ML. Controversies in Otolaryngology. New York: Thieme; 2001. pp. 203-17. 8. Roth TN, Haeusler R. Inside-out technique cholesteatoma surgery: a retrospective long term analysis of 604 operated ears between 1992 and 2006. Oto Neurotol. 2009;30 (1):59-63. 9. Sanna M, Kharaist T, Falcioni M, Russo A, Taibah A. The Temporal Bone: A Manual for Dissection and Surgical Approaches. Stuttgart, New York: Thieme; 2006. pp. 22-38. 10. Tos M. Manual of middle ear surgery: mastoid surgery and reconstructive procedures. New York: Thieme; 1995. pp. 275-82. 11. World News. Modified Radical Mastoidectomy The Insideout Technique. [online] Available from http://wn.com/ Modified_Radical_Mastoidectomy__The_Inside_out_ technique.

The Surgical Technique of Otoplasty 124

CHAPTER

16

The Surgical Management of Congenital Cholesteatoma Jennings R Boyette, Gresham T Richter

INDICATIONS FOR THE SURGERY Congenital cholesteatomas (CCs) are rare keratin-filled anomalies that are present at birth in the middle ear. The etiology of CCs remains somewhat controversial with many theories proposed. The theory with most supportive evidence suggests that CCs arise from retained epithelial rests within the middle ear.1-3 The most popularly noted presentation of CCs is a white pearl in the anterior-superior quadrant of the middle ear behind an intact tympanic membrane (TM). Recent evidence, however, indicates that most CCs present with open sacs and disseminated disease in the middle ear. Small, single-quadrant disease occurs in less than 40% of cases.4,5 Moreover, CCs are now known to have the potential to occur anywhere within the middle ear or mastoid cavity. According to criteria originally proposed by Derlacki and Clemis, cholesteatomas are considered congenital if they are discovered behind an intact TM in a patient with no history of otorrhea, prior ear surgery, or TM perforations.6 In contrast to acquired cholesteatomas, the development of CC appears to be independent of eustachian tube dysfunction.7 With time, CC can expand to engulf the ossicular chain, mastoid cavity and sometimes the TM. Severity of disease correlates with age of presentation. Potsic et al.8 have found a difference between age of presentation with (5.6 years) and without (3.9 years) ossicular or mastoid invasion. Once the TM is ruptured, differentiating CC from acquired type cholesteatomas is difficult. Presently, CC cannot be confidently distinguished from their acquired counterparts by histology.

incidentally on physical examination, pneumatic otoscopy, computed tomography (CT) radiography, or during myringotomy procedures.4 Acute or chronic serous otitis media may be an associated finding in as many as 40–49% of patients.4,8 As the cholesteatoma grows, it can cause a slight obstruction of the eustachian tube which causes negative middle pressures and tympanic retraction that ultimately allows for identification.1 As CCs continue to grow, they may rupture the TM, thus converting to the “open” variety. “Open” type CCs are commonly diagnosed in the teenage years.9 Surgical management is the mainstay of therapy for all CCs. Medical treatment options currently do not exist. The age, at presentation and extent of disease, ultimately directs the degree and type of surgical management. Early lesions confined within the anterosuperior quadrant may be addressed through a transcanal, endaural, or modified sleeve approach (Fig. 1). Extensive disease, in the older child, shall be addressed with diligent extirpation with the expectation of ossicular erosion and need of TM and/ or prosthetic ossicular reconstruction. Patients and families should be counseled regarding potential unexpected intraoperative findings and the risk of recidivistic disease.

SPECIFIC PREOPERATIVE EVALUATION

Presentation Congenital cholesteatomas are slow-growing cysts that tend to present at around 4–6 years of age.1,8 Most common presenting symptoms are hearing loss and otorrhea.9 However, approximately 80% of patients are asymptomatic at presentation.8 Most cases are detected

Fig. 1: Otoscopic view of a congenital cholesteatoma (cc) behind the tympanic membrane in the anterior-superior quadrant of the middle ear space

The Surgical Management of Congenital Cholesteatoma 125 Surgical Assessment Physical examination will help identify patients with limited and definable disease, such as the simple keratin pearl (Fig. 1). This can often be approached with a trans­canal or endaural approach. CC expansion seems to follow consistent pathways with time. If disease originates in the anterosuperior quadrant, CC will extend posteriorly toward the incudostapedial joint, around the incus and into the attic, superiorly into the epitympanum and antrum, and anteriorly to obstruct the eustachian tube.1 Once the mastoid is involved, progression occurs along less defined pathways similar to that of acquired cholesteatomas. Similarly, CCs have been shown to arise from any location within the middle ear and mastoid. Disease is often severe at presentation when this occurs. Figure 2 provides an algorithm for assessment and management of CCs. The preoperative evaluation should include an audiologic assessment and CT of the temporal bones. An audiogram is simply important to establish preoperative hearing levels. In early disease, a subtle conductive loss with type A or type A(s) tympanograms will be present. With disease progression, otic infections, conductive hearing loss, tympanic disruption and unclear disease margins are found. These signs indicate advanced disease and 60% of these patients will have stapes suprastructure or incus erosion.4,8 In these children, a temporal

bone CT scan is recommended to determine the extent of disease and plan for the appropriate surgical approach.10,11 Preoperative CT findings are comparable to surgical findings in approximately 70% of CCs with a sensitivity and specificity of 68.6% and 87.5% respectively with regard to predicting mastoid involvement.3 The role for magnetic resonance imaging (MRI) in the preoperative evaluation of CCs remains limited. Establishing the stage and extent of disease preoperatively has been found to be one of the most important factors in treatment success.12 Based upon their extensive series, Potsic et al.5 and Nelson et al.4 developed staging systems based upon the extent of disease and subsequent recurrence rates. Their suggestions for surgical planning based upon disease severity are summarized in Table 1.

ANESTHETIC CONSIDERATIONS Surgical management of CCs routinely requires general anesthesia with intubation. Prolonged facial nerve monitoring is expected and precludes the use of paralytics during anesthesia. Upon the completion of cholesteatoma removal and tympanic replacement (or repair), anesthesiologist should be informed to refrain from using nitric oxide inhalational anesthetic as this may expand the middle ear space and prevent appropriate tympanic adherence.

Fig. 2: Simple algorithm for the assessment and management of congenital cholesteatoma

126 Otology and Lateral Skull Base Table 1: Staging systems proposed by Nelson et al.4 and Potsic et al.5,8 with descriptions, surgical approaches and recurrence rates Author

Stage

Description

Cases (%)

Surgical approach

Recurrence rate (%)

Nelson et al.

I

Confined to middle ear with no ossicular involvement

31*

Extended tympanotomy

0

II

Involves ossicular chain, posterior mesotympanum and/or superior quadrant of the attic

69

Extended tympanotomy Scutum reduction Possible atticotomy

34

III

Middle ear and mastoid obliteration with ossicular erosion

26

Tympanomastoidectomy

56

I–II

Involves one (I) or more (II) middle ear quadrants without ossicular invasion or mastoid extension

I: 40 II: 14

Not reported

I: 14 II: 33

III

Ossicular erosion but no mastoid extension

23

Not reported

41

IV

Mastoid infiltration

23

Tympanomastoidectomy

67

Potsic et al.

*data extracted

SURGICAL APPROACHES AND STEPS

Similar to acquired cholesteatomas, the only treatment for CC is surgical. The goals of surgery are to remove all disease, create a safe and dry ear, prevent recurrence, and preserve or restore hearing. The location and extent of disease will determine the best surgical option for disease extirpation and maximal hearing results. A continuum of surgical options exists for the management of CC that range from minimally invasive transcanal techniques to extensive canal wall down mastoidectomies. The surgical approach depends upon the severity of disease. Disease severity may not always be evident, despite sufficient preoperative assessment, and preparation for more invasive approaches should be entertained at the time of surgery. In this light, placement of a facial nerve monitor for all approaches is highly recommended.

Transcanal For disease limited to the anterior mesotympanum with no ossicular involvement, a transcanal tympanoplasty approach frequently allows for good visualization and extirpation of the cholesteatoma (Fig. 3). As opposed to middle ear surgery for acquired cholesteatomas, there is rarely any inflammatory reaction or adhesion, and a plane between the cholesteatoma and middle ear mucosa can be developed. Entrance into the epitympanum, sometimes, occurs anterior to the neck of the malleus along the tensor tympani. This may be difficult to visualize and dissection around this site is best completed with an extended

Fig. 3: Intraoperative endoscopic view of congenital cholesteatoma (cc) anterior to malleus (m) and incus (i)

tympanotomy. The goal of this technique is to remove the cholesteatoma as an intact keratin pearl. Newly developed endoscopes have proven useful in dissection of CC.11 This is particularly true during the transcanal technique to examine evidence of remaining disease in the epitympanum. If disruption of the CC occurs near the epitympanum, then endoscopic visualization is highly recommended.

Surgical Steps 1. Perform complete auricular block and canal injections with 1% lidocaine with 1:100,000 epinephrine. 2. Placement of facial nerve monitor probes followed by prepping and drape.

The Surgical Management of Congenital Cholesteatoma 127 3. Otomicroscope is brought into the field. 4. Place the largest otic speculum that the external auditory canal (EAC) can accommodate. Copious irrigation of the canal is performed. 5. Vertical posterior canal and 6 o’clock and 12 o’clock canal incisions are made, with care to leave a 4–5 mm tympanomeatal flap. 6. The tympanomeatal flap is raised to enter middle ear space below annulus. 7. Begin to raise TM inferiorly in hypotympanum to prevent disruption of ossicular chain and CC. 8. Use sickle knife to follow chorda tympani between malleus and incus. 9. Identify the neck of the malleus superiorly and dissect TM off short process and neck of malleus to identify CC. 10. Carefully dissect TM from CC anteriorly. 11. Extended tympanotomy anteriorly may be required at this point and should be performed with round knife at anterior canal wall 2–3 mm from annulus and should connect with previously raised posterior tympanomeatal flap (Fig. 4A). 12. Raise TM from cholesteatoma. Sometimes, a small amount of the TM needs to be removed with CC to prevent disruption of the CC sac (Fig. 4B). 13. Dissect CC from undersurface and anterior edge of malleus. 14. Use suction to hold CC as McCabe or whirlybird dissector is used to free it from the epitympanum. 15. Release CC from any attachments to promontory. 16. Elevate CC carefully from middle ear space using large suction with period release of minor attachments using a sickle knife or Rosen dissector (as preferred).

A

17. Examine epitympanum with small mirror or endoscopy to ensure disease elimination. 18. Small fragments may be on the anterior surface of the malleus which should be carefully scraped with a sharp curved instrument. 19. Copious irrigation should be performed. 20. Replace TM or repair using perichondrial graft, harvested from tragus or temporalis fascia. 21. Cover TM with gelfoam followed by canal infusion of bacitracin antibiotic ointment.

Endaural “The endaural incision provides wide exposure of the EAC and tympanic membrane without the use of a handheld otologic speculum and without creating a postauricular incision.” Additional advantages of this incision are that it doesn’t interrupt cutaneous innervation of the pinna, does not require a postoperative mastoid dressing, reduces the chance of ear canal collapse seen in postauricular incisions and allows reasonable access to epitympanum. This is best used for moderately sized closed keratin sac CC (Stage II) where more exposure of the epitympanum and mesotympanum are desired. Along with the steps described for transcanal technique, the following should be employed during the initial exposure. Two small selfretaining retractors are necessary (2 point Weitlanders) for the endaural exposure.

Surgical Steps 1. Using a nasal speculum, an incision is made along the superior EAC at the 10 o’clock position along the bony cartilaginous junction to the incisura of the external ear (Fig. 5).

B

Figs 4A and B: (A) Extended tympanotomy with anterior canal wall incision created by round knife 2–3 mm from the annulus; (B) Tympanomeatal flap (tmf) raised from posterior and anterior canal walls and off the malleus handle

128 Otology and Lateral Skull Base 2. A periosteal elevator is used to develop the flap until the fibrous annulus is encountered. 3. The annulus is separated from its attachments in the sulcus. 4. The attachments of the malleus handle to the pars tensa are severed. 5. The tympanic membrane is left tethered to the umbo to prevent lateralization of the TM postoperatively. 6. The tympanic cavity can now be examined and CC removed. Use of endoscopes can allow for further visualization. 7. The TM is then replaced, secured with gelfoam on both sides, and antibiotic ointment used to fill the canal. Fig. 5: Endaural incision, from external auditory canal (EAC) to incisura, prior to retractor placement in preparation of removing congenital cholesteatoma

2. With the nasal speculum still in place, an angled beaver blade is used to create a curvilinear incision which is made just medial to the bony cartilaginous septum of the posterior EAC. 3. The posterior canal wall skin is then elevated slightly posteriorly using the same blade. 4. A small periosteal elevator is then used to pull the lateral EAC skin over the bony EAC to retract the cartilaginous EAC posteriorly. 5. Two self-retaining Weitlander retractors are placed to maintain this widened EAC. 6. Closure at the end of the case is performed by suturing the superior incision into the EAC with a running 6.0 chromic suture.

Extended Tympanotomy An extended tympanotomy can be employed during any surgical approach to CCs to provide better exposure and access to the middle ear and CC. However, the extended tympanotomy is more commonly used during transcanal and endaural approaches. The extended tympanotomy can include: inferiorly-based flap,13,14 a superiorly-based flap,15 a modified sleeve technique16 or using a transcanal antrotomy.17 The elected names of extended tympanotomies appropriately describe the degree and site of tympanomeatal flap dissection for better exposure of the CC. The novel modified sleeve techniques require specific elaboration and is created by the following steps.

Surgical Steps 1. In the modified sleeve technique, the tympanomeatal flap is developed circumferentially. A circumferential incision is made in the canal wall approximately 6 mm lateral to the annulus.

Intact Canal Wall For disease that is more extensive than an isolated pearl, a postauricular tympanomastoidectomy approach can allow for improved exposure and extirpation of the cholesteatoma that would not be possible via a transcanal approach.

Surgical Steps 1. Facial nerve monitor established. 2. Complete auricular block and canal injections are performed with 1% lidocaine with 1:100,000 epinephrine if a tympanomeatal flap will be elevated as part of the procedure. The postauricular skin is also injected. 3. Following prepping and draping, the canal incisions are made within the EAC using the microscope. Superior and inferior incisions and flap development follow as described above for the transcanal approach. 4. The postauricular incision extends from the root of the superior helix to the mastoid tip. It should be placed posterior to the postauricular sulcus. In younger children, inferior extension of the incision should be avoided due to risk to the facial nerve. 5. At this point, exposure of the temporalis fascia allows for harvesting of a graft if needed for tympanic membrane reconstruction. 6. A T-shaped incision is made in the periosteum and a periosteal elevator is used to expose the mastoid bone. 7. Self-retaining retractors are used to maintain exposure. Landmarks of the spine of Henle and Macewen’s triangle can be identified. 8. The authors prefer to perform canal incisions at this point with exposure of canal skin envelope from the postauricular approach. 9. Once the entire mastoid bone is exposed from temporalis muscle to mastoid tip, then a large cutting burr (5.0) with constant irrigation is used to remove the cortex and follow the tegmen, posterior canal and sinodural angle into the mastoid cavity. Initial penetration

The Surgical Management of Congenital Cholesteatoma 129 into the mastoid cavity should be made parallel to the EAC and linea temporalis, to form a triangular cavity. 10. Koerner’s septum will be encountered, and will need to be removed, prior to entry into the mastoid antrum. 11. Once the horizontal canal is visible, a smaller cutting burr is used to open the mastoid antrum along the tegmen and posterior canal wall until the incus is visible. 12. At this point, the cholesteatoma is often identified and gentle traction, using various blunt and sharp instruments, is performed to elevate the cholesteatoma from the mastoid cavity toward the antrum and ossicular chain. 13. This approach should allow considerable exposure of the incus, which can be removed for CC involvement. This requires disarticulation from the stapes (if not already occurred) and sniping the malleus neck. Both the incus and head of malleus can then be removed with infiltrating cholesteatoma. 14. For disease extending into the posterior mesotympanum, the facial recess can be opened to facilitate exposure. “Use of a 2-mm or 3-mm diamond burr is recommended for this step.” The posterior canal wall is thinned. The facial recess is identified by noting the direction of the short process of the incus that points to the location of the facial nerve. Careful removal of bone between the chorda tympani and facial nerve is performed in a parallel direction to the nerves. The incus buttress may be removed to facilitate exposure if the ossicular chain has been disarticulated. 15. Extensive CC will infiltrate the epitympanum, the eustachian tube orifice and tensor tympani. Dissection from these sites is performed with care to avoid the facial nerve. Intermittent testing of the location of the nerve is appropriate. 16. Once the CC has been removed, the mastoid cavity is irrigated and the tympanic membrane repaired as needed. 17. Ossicular reconstruction can be performed at this time or staged for a second-look procedure. 18. The tympanic membrane can be repaired or bolstered using standard underlay techniques. Material for tympanic repair can be tragal cartilage, tragal perichondrium, or temporalis fascia as preferred by the surgeon. 19. The periosteum and subcutaneous tissue is closed with 3.0-4.0 vicryl sutures. Skin can be closed with a running 6-0 chromic suture or interrupted subcuti­ cular 5.0 monocryl. 20. Wick sponges can be placed to retain the form of the EAC. A major disadvantage to an intact canal wall procedure is limited exposure of the epitympanum and sinus tympani. Recidivistic disease is common (up to 67%) in stage III or stage IV cholesteatomas, and limited

exposure of these areas can lead to higher rates of recidivistic disease.18

Canal Wall Down A canal wall down approach allows for improved visualization and removal of the CC, especially when extensive disease of the epitympanum, facial recess, and sinus tympani is present. When multiple tympanomastoidectomies are necessary to remove retained cholesteatoma, then the canal wall down approach seems appropriate as a last resort for complete disease extirpation. Of course, removing the posterior EAC wall is disadvantageous. This is especially so because removing the wall requires significant maintenance and cleaning of the mastoid bowl, which is generally not well tolerated in younger patients. Water restrictions of a canal wall down procedure limit swimming and water-related activities, which are very important to some children. More importantly, the posterior canal wall is important to provide some flexibility in hearing-aid fitting. Proper discussion regarding these drawbacks with the family is necessary before proceeding.

Surgical Steps 1. The steps for the canal wall up approach are initially performed. 2. Once the level of the facial nerve has been identified, the posterior canal wall can be taken down with a cutting or diamond burr depending upon the surgical skill and confidence. It is important that the mastoid bowl be well saucerized. This helps with visualization and soft tissue closure. 3. The location of the facial nerve establishes the height of the new mastoid cavity. It is important to remove the ridge of bone extending up from the facial nerve (the facial ridge), in order to completely open the two cavities and to assist in cleaning of the mastoid bowl postoperatively. 4. Ossicular reconstruction can be performed at this time or staged for a second-look procedure. 5. A meatoplasty is carried out to allow for improved drainage, aeration, and visualization of the cavity in the clinic. The previously made canal incisions for the tympanomeatal flap are extended laterally into the conchal cartilage. A section of cartilage can then be removed posteriorly while carefully leaving the skin intact on one side of the canal. 6. An anterior meatoplasty can also be performed by removing a portion of the tragus. 7. At this point, the TM can be reconstructed if needed. With an intact TM, the tympanomeatal flap can now be draped back into position and secured with gelfoam packing.

130 Otology and Lateral Skull Base 8. Wick sponges can be placed to retain the form of the mastoid bowl and EAC. 9. Some authors would suggest filling the mastoid bowl at this point with retained cortical bone pate, cut fragments of harvested cartilage, or demineralized bone matrix.

Postoperative Considerations Postoperative care, for all the above procedures, includes incision maintenance with 2–3 daily cleaning and application of antibiotic ointment. Patients follow up postoperatively in 2 weeks. When a wick sponge is placed, antibiotic otic drops are applied daily beginning 3–5 days before returning to clinic. This allows for easy cleaning and examination of the EAC upon follow-up. A mastoid dressing should be applied after tympanomastoidectomy procedures and removed in 1–2 days postoperatively. The authors provide a Glasscock dressing to protect the ear during sleep for all procedures. Patients are informed not to blow their nose and should avoid strenuous activity for 2 weeks.

COMPLICATIONS Complications involved in removing CCs are those associated with most other otologic surgeries. The facial nerve, sigmoid sinus, and tegmen must be carefully protected at all times. Facial nerve monitoring is recommended for all approaches. Incomplete removal of the cholesteatoma and recidivistic disease is a primary concern with congenital cholesteatomas and proper surgical planning can prevent this complication. Whether to perform a single-stage procedure or planned second look should be decided based on preoperative CT imaging findings and intraoperative findings. Recidivistic disease is common (up to 67%) in stage III or IV CCs;3 therefore, once ossicular or mastoid involvement is discovered, one should consider a second-look procedure and staging ossiculoplasty for such extensive disease. In two large case series, over 34% of patients with ossicular involvement had recidivistic disease.4,5 In a study of 53 pediatric patients treated for cholesteatomas, the seven patients who were found to have recurrent or residual disease initially had stapes suprastructure involvement.19 Therefore, the authors recommend a second-look procedure with staged ossiculoplasty for extensive disease with ossicular involvement. The use of silastic in the middle ear is also recommended when a second-look procedure is planned. On second-look procedures, evidence of residual disease has been reported from 8% to 81%, and is thought to be commonly related to incomplete removal at the sinus tympani and facial recess.3,20 Therefore, if the degree

of residual cholesteatoma identified on second-look is more extensive than a simple pearl, or involves the sinus tympani or epitympanum, a more extensive approach is recommended via a canal wall down mastoidectomy. Otherwise, if residual disease is fairly limited, a canal wall up procedure is once again used for removal. Hearing results following cholesteatoma removal are largely dependent on the preoperative hearing levels and the degree of ossicular chain involvement. Nelson et al. reported preoperative hearing loss ranging from an average 12.5 dB for limited middle ear disease, up to an average of 47.7 dB loss for disease extending into the mastoid.4

SPECIAL INSTRUMENTS USED FOR THE SURGERY

The use of rigid endoscopes, such as those commonly employed in nasal surgery, can provide extended views into the middle ear space that cannot be achieved with the microscope; 4-mm or 2.7-mm scopes can be used, with the 4-mm scope providing better visualization and the 2.7-mm providing easier access; 30° and 45° scopes are most commonly used, as insertion of a 70° scope can be difficult in this small area (Fig. 6). Presutti et al. have described their experience with endoscopes in acquired cholesteatomas and found the incidence of residual disease after microscopic resection to be 37.5% in their series.21 The most common site was the sinus tympani, followed by the anterior epitympanum, and protympanum.21 Since residual CCs are most often found in the sinus tympani, the use of endoscopes to examine this area can help to confirm complete resection and determine the need for more extensive surgical procedures.

Fig. 6: Endoscopic view of epitympanum (e) anterior to the

malleus (m) following congenital cholesteatoma removal from anterior superior quadrant using a 2.7-mm 30° endoscope

The Surgical Management of Congenital Cholesteatoma 131

NEW

TECHNIQUES

The success of the surgery to remove CC’s depends on full exposure of the cholesteatoma. While the hierarchy of procedures—from transcanal to CWD mastoidectomy— to gain this exposure increases, the morbidity of these procedures also increases. Therefore, new techniques are primarily concerned with increasing visibility through minimally invasive approaches. The extended tympanotomy approaches discussed elsewhere in this chapter are good examples of these new techniques. Retrograde mastoidectomy with canal wall reconstruction, such as the technique described by Dornhoffer, allows for increased exposure of the cholesteatoma while decreasing postoperative morbidity related to frequent bowl cleanings and water precautions.22 This technique is particularly useful with epitympanic cholesteatomas, whereby the cholesteatoma is followed posteriorly by removing the canal wall. The canal wall defect is then reconstructed with concha cymba cartilage. The use of endoscopes to increase visualization has also facilitated the removal of cholesteatomas through less invasive techniques. This new application of existing equipment is described later in the chapter during the discussion on special instrumentation.

OTHER

TREATMENT OPTIONS

Surgical excision continues to be the only reliable treatment option for congenital cholesteatomas. However, with open variety cholesteatomas treatment with otic drops prior to surgical intervention may facilitate the resection and ease patients’ symptoms. Otic formulations containing a fluoroquinolone and a steroid (such as ciprofloxacin and dexamethasone) are beneficial at decreasing otorrhea and diminishing the inflammatory reaction caused by the cholesteatoma. Persistent eustachian tube dysfunction may also impact the postoperative success of the tympanic repair. Children with signs of eustachian tube dysfunction may particularly benefit from treatment with a nasal steroid in order to restore a normal, aerated middle ear environment.

REFERENCES 1. Koltai PJ, Nelson M, Castellon RJ, et al. The natural history of congenital cholesteatoma. Arch Otolaryngol Head Neck Surg. 2002;128(7):804-9. 2. Kazahaya K, Potsic WP. Congential cholesteatoma. Curr Opin Otolaryngol Head Neck Surg. 2004;12(5):398-403. 3. Choi HG, Park KH, Park SN, et al. Clinical experience of 71 cases of congenital middle ear cholesteatoma. Acta Otolaryngol. 2010;130(1):62-7.

4. Nelson M, Roger G, Koltai PJ, et al. Congenital cholesteatoma: classification, management, and outcome. Arch Otolaryngol Head Neck Surg. 2002;128(7):810-4. 5. Potsic WP, Samadi DS, Marsh RR, et al. A staging system for congenital cholesteatoma. Arch Otolaryngol Head Neck Surg. 2002;128(9):1009-12. 6. Derlacki EL, Clemis JD. Congenital cholesteatoma of the middle ear and mastoid. Ann Otol Rhinol Laryngol. 1965;74 (3):706-27. 7. Dornhoffer J. Cartilage tympanoplasty: indications, techniques, and outcomes in a 1,000-patient series. Laryngoscope. 2003;113(11):1844-56. 8. Potsic WP, Koman SB, Samadi DS, et al. Congenital cholesteatoma: 20 years’ experience at The Children’s Hospital of Philadelphia. Otolaryngol Head Neck Surg. 2002;126 (4):409-14. 9. Kojima H, Tanaka Y, Shiwa M, et al. Congenital cholesteatoma clinical features and surgical results. Am J Otolaryngol. 2006;27(5):299-305. 10. Manolis EN, Filippou DK, Tsoumakas C, et al. Radiologic evaluation of the ear anatomy in pediatric cholesteatoma. J Craniofac Surg. 2009;20(3):807-10.16. 11. Marchioni D, Mattioli F, Cobelli M, et al. CT morphological evaluation of anterior epitympanic recess in patients with attic cholesteatoma. Eur Arch Otorhinolaryngol. 2009;266 (8):1183-9. 12. Bennett M, Warren F, Jackson GC, et al. Congenital cholesteatoma: theories, facts, and 53 patients. Otolaryngol Clin North Am. 2006;39(6):1081-94. 13. Levenson MJ, Parisier SC, Chute P, et al. A review of twenty congenital cholesteatomas of the middle ear in children. Otolaryngol Head Neck Surg. 1986;94(5):560-7. 14. McGill T, Rahbar R. Surgery of the ear and temporal bone. In: Congenital cholesteatoma. Philadelphia: Lippincott Williams & Wilkins; 2005. pp. 337-44. 15. Sooy CD, Sooy FA. Transcanal management of benign middle ear lesions involving the anterior middle ear cleft. Laryngoscope. 1985;95(6):671-3. 16. Park HJ, Park GH, Shin JE, et al. Modified sleeve tympanotomy approach for removal of congenital cholesteatoma. J Laryngol Otol. 2008;122(12):1365-7. 17. Holt JJ. Transcanal antrotomy. Laryngoscope. 2008;118 (11): 2036-9. 18. Austin DF. Single-stage surgery for cholesteatoma: an actuarial analysis. Am J Otol. 1989;10(6):419-25. 19. Shirazi MA, Muzaffar K, Leonetti JP, et al. Surgical treatment of pediatric cholesteatomas. Laryngoscope. 2006;116(9): 1603-7. 20. Darrouzet V, Duclos JY, Portmann D, et al. Congenital middle ear cholesteatomas in children: our experience in 34 cases. Otolaryngol Head Neck Surg. 2002;126(1): 34-40. 21. Presutti L, Marchioni D, Mattioli F, et al. Endoscopic management of acquired cholesteatoma: our experience. J Otolaryngol Head Neck Surg. 2008;37(4):481-7.22. 22. Dornhoffer JL. Retrograde mastoidectomy with canal wall reconstruction: a follow-up report. Otol Neurotol. 2004 Sep;25(5):653-60.

CHAPTER

17

The Technique of Otoendoscopy for Cholesteatoma Surgery Mohamed Badr-El-Dine

INTRODUCTION Although the specialty of otolaryngology has been in the forefront of the development of endoscopic techniques, the otologists and skull base surgeons have been much less enthusiastic about its possible indications. Despite the illumination and magnification offered by the operative microscope, it has proved distinct limitations. The surgeon can visualize structures only directly ahead and is unable to see around objects. This straightline view offered by the microscope resulted in certain blind recesses during middle ear surgery. These limitations can be overcome with the use of endoscope, which allows “looking around the corner”.1 Furthermore, the surgical management of cholesteatoma remains a controversial subject almost more than 100 years after the first successful mastoidectomy was performed. The criteria published in the literature for selection of the technique used in cholesteatoma surgery are numerable and include patient factors such as age; anatomic factors such as the degree of cellularity of the mastoid; pathologic factors that depend on the degree of extension of cholesteatoma; functional factors that concern hearing affection, and social factors related to the availability of the patient for follow-up.2 During the past decades, middle ear surgery has increasingly relied on the endoscope particularly when dealing with cholesteatoma. Endoscope proved its efficiency and reliability in extirpation of cholesteatoma especially from blind pockets. It is important to highlight the usefulness of otoendoscopy as a tool that can influence surgical decision-making and promote functional ear surgery.3-5 Functional endoscopic ear surgery (EES) is opening new horizons and changing the vision the way cholesteatoma is treated.4-6 Before the introduction of EES, inaccessible areas necessitated “loop-around ways” to fulfill the task. Surgeon was obliged to drill more healthy bone aiming to improve visualization. Over the past decade, the use of otoendoscopy to visualize the recesses of the middle ear and mastoid cavity has been gaining more and

more advocates. However, its intraoperative use to eradicate the disease and achieve total removal still carries lots of controversies. Many studies in the literature have evaluated the effectiveness of otoendoscopy to achieve total control over the pathology particularly cholesteatoma extension into the sinus tympani (ST).3,6-8 There are two ways to explore the middle ear using the endoscope: 1. Exclusive endoscopic transcanal approach where the whole surgery is performed by the endoscope. Microscope will only be used if the pathology is found extending extensively into the mastoid tip. This exclusive transcanal endoscopic approach can be further subdivided according to Tarabichi9 into three basic approaches. These are: (1) transcanal management of limited cholesteatoma; (2) open endoscopic management of cholesteatoma and (3) extended transcanal approach to cholesteatoma.9 Preoperative computed tomography (CT) evaluation is mandatory as a rough guide to the assessment of the disease and the involvement of the mastoid cavity. However, intraoperative evaluation remains the main guide to the extent of disease. That is why before undergoing any exclusive endoscopic procedure, all patients were informed of the possibility of extending their surgery to a transmastoid approach in the event that the cholesteatoma could not be satisfactorily eradicated by the transcanal endoscopic approach.9,10 2. Combined endoscopic/microscopic approach (better called endoscope-assisted ear surgery) in which the endoscope is used as a complementary tool to the microscope. It can be further subdivided into: (i) active endoscopic surgery where endoscope is used from the beginning of the surgery together with the microscope and the process of disease removal is made all through the procedure using both microscope and endoscope alternatively; i.e. alternating between the microscope and the endoscope according to the need all through the eradication phase. This can be further subdivided into: (a) strictly transcanal endoscopic dissection and

The Technique of Otoendoscopy for Cholesteatoma Surgery 133 (b) combined transcanal/transmastoid dissection. (ii) Check-up endoscopic surgery where the surgeon uses the endoscope only at the end of the microscopic procedure to explore and/or confirm total eradication of pathology from hidden recess such as ST or anterior epitympanic recess. In case of detection of any residual pathology, it will be removed under endoscopic control. Technically, the endoscope-assisted ear surgery for cholesteatoma removal provides very versatile approach. The endoscope can be passed transcanal transtympanical to adequately explore different middle ear (ME) recesses, particularly the ST. Furthermore, endoscope can be passed transmastoid into the ME through the aditus into the attic and control the entire panorama of the ME from above. The whole attic with the ossicles, the anterior epitympanic recess and the supratubal recess together with the Eustachian tube orifice are perfectly controlled. The facial recess, facial nerve with the oval window, and stapes are also clearly visualized. The tensor tympani tendon and fold are also viewed and reached from above and even the promontory can be inspected together with the underlying surface of the tympanic membrane, if present (Fig. 1).

Fig. 1: Right ear showing transmastoid endoscopic view using 30° scope, 3 mm diameter. The anterior epitympanic recess with the head of malleus attached medially by the tensor tympanic tendon are perfectly visualized. The curved suction cannula passing transcanally cleaning the orifice of the Eustachian tube (*) is seen through the opening created after disrupting the tensor tympani fold. (**) edge of the tensor tympani fold (LSCC: Lateral semicircular canal; Ant. Ep. Rc: Anterior epitympanic recess)

Additionally, the advantages of the endoscope are deeply appreciated in cases with intact ossicular chain and good preoperative hearing. Endoscope provides incomparable control to completely remove some limited cholesteatoma matrix medial and anterior to the ossicles. For the advocates of the exclusive endoscopic surgery, cholesteatoma was defined as being endoscopically accessible when it did not extend beyond the level of the laryngeal squamous cell carcinoma (LSCC).9,10 In case of cholesteatoma inaccessible even with angled instruments under direct vision with angled endoscopes, traditional canal wall-up (CWU) mastoidectomy was performed and removal of pathology will continue both microscopically and endoscopically. The endoscopic technique in such situation will progress in a combined transmastoid/transcanal fashion. Migirov et al.10 followed that same technique and clarified the limits for the exclusive endoscopic surgery for acquired cholesteatoma. In her series, all cases in which the disease extended beyond the limit of the LSCC where converted into classic retroauricular tympanomastoidectomies.10 Based on authors’ experience, although the exclusive endoscopic technique offers excellent control over limited pathology, the endoscope-assisted ear surgery provides the widest array of approaches to deal with all kinds of pathology whatever the extent and severity. This strategy markedly refined the control over the disease, significantly decreased the risk, improved visualization and reduced operative time. Subsequently, endoscope-assisted ear surgery provided effective control over the disease thus reduced the need to drill superfluous bone “only for the sake of visualization” therefore, establishing the concept of functional EES. Keeping in the back of our mind the pathogenesis of cholesteatoma together with the possibility of recurrence due to retraction (the primary reason of recurrent pathology), drilling of bone around the supporting areas especially that of the posterior canal wall near the internal border of the scutum is not justified, as it is not physiologic. It jeopardizes the “bony-soft tissue inter-relation” and may favor the incidence of future retraction, consequently recurrence.11 The authors agree with Hinohira et al.12 that such exposure increases significantly the incidence of retraction even if followed with reconstruction: scutumplasty. Conversely, when such defects are present due to bone destruction caused originally by the disease, complex repair by fashioned cartilage and/or bone pâté/autograft should be performed, viz. scutumplasty).12

134 Otology and Lateral Skull Base

PREOPERATIVE EVALUATION Preoperative assessment included microscopic, otoendoscopic office examination, full audiometric evaluation and high-resolution multislice CT of the middle ear and temporal bone. Computed tomography usually cannot provide information on the exact extension of a cholesteatoma because of the similar opacification caused by reactive changes in the middle ear and mastoid (i.e. inflamed mucosa, fluid) and the cholesteatoma itself. Because CT is still the standard criterion in preoperative assessment of cholesteatoma; however, the final decision on the choice of intervention is made intraoperatively according to the surgical findings.9,10 Standard preoperative audiogram is performed to evaluate the severity of hearing loss. While postoperative changes in hearing levels were defined as being significant when the postoperative pure-tone averages of air-bone thresholds at 500, 1,000 and 2,000 Hz increased or dropped by 10 dB or higher.

INSTRUMENTATION AND SURGICAL TECHNIQUE

Detailed Description of the Endoscopic Ear Surgery Setup: Whether Exclusive Endoscopic or Endoscope Assisted Ear Surgery Although the basic features of all middle ear instruments may seem similar and satisfying, however, with a more

specialized look, the search for easier, quicker and more satisfying instruments is mandatory. New technologies have stimulated the creation of special endoscopic equipment and micro-instruments particularly designed to fulfill the exclusive requirements of EES. Endoscopic surgery has its own peculiarities as the surgeon works practically with one hand as the other hand is always holding the endoscope, also in many instances uses angled vision endoscopes to work around the corner. A full standard microsurgical set is required during any endoscopic procedure. In addition, the need for specially designed instruments adapted for exclusive work under angled endoscopes is fundamental. 1. Operating room setup: The operating room for ear surgery should display state-of-the-art instrumentation. The surgeon should be in a comfortable working position during the prolonged holding of the endoscope super-mounted with the endoscopic video camera. Even when planning an exclusive EES, still microscope is an essential part of the surgical setting. The microscope is placed in the sterile field ready to be used alternatively with the endoscope. The patient is placed supine on the operating room table in the normal otologic position (Fig. 2). The endoscopic tower is placed directly facing the surgeon while the monitor is in direct level with the surgeon’s eyes. Because the surgeon is not looking down into the eyepiece of the endoscope and instead is looking directly forward at the video screen, proper alignment of these components is essential to keep the surgeon orientation to the surgical field and ensure comfortable working position.

Fig. 2: The patient and operating room table, equipments and personnel are shown in diagram

The Technique of Otoendoscopy for Cholesteatoma Surgery 135 2. Standard instruments for microscopic ear surgery: In general, a full set of microsurgical instruments is required, and these are very familiar to the practicing otologists. Microforceps, microscissors, microhooks, needles, elevators, curettes and knives. Suction cannulas and adaptors with control hole (Fig. 3). 3. Endoscopes and special instruments for endoscopic ear surgery: a. Rigid endoscopes: Endoscopes have proved increasing benefit in ear surgery. Incorporating the endoscope into the surgical armamentarium in otology had contributed much to the concept of minimally invasive surgery. This is because the operating microscope requires wide viewing portals for adequate illumination and visualization of the operative field contrary to endoscope which provide direct vision with illumination to the target field, thus avoiding the need for extra exposure and extra drilling. Endoscopes have many proved advantages over the microscope, including wider angle of view, better visualization of structures that are parallel to the axis of the microscope, visualization of deep recesses and hidden structures, i.e. around the corner, and the ability to visualize beyond the shaft of the surgical instruments. On the other hand, several disadvantages of endoscopes include loss of depth of perception and binocular vision, the inevitable one-handed surgical technique involved, the need of a strictly bloodless field (hence meticulous attention to hemostasis is essential), fogging and smearing of the tip of the endoscope, the mandatory need for reliable physician training,

and the cost of the equipments.3,4,9 The design of the Hopkins rod lens system developed to yield endoscopes of variable length, diameters, and angles of view. The rigid endoscopes commonly used for ear surgery are either 2.7 mm, 3 mm or 4 mm in diameter. All the new endoscopes are now autoclavable (Fig. 4). The working length is 18 cm, 11 cm and 6 cm. The larger the diameter, the better the image displays and the more light it can transmit to the operative field. The 0° and 30° angled scopes are the most commonly used followed by the 45°. Endoscope with a greater angle, such as the 70°, is difficult and disorienting to work with and is only used for inspection in limited spots as the ST may lie very deep in 20% of cases (Fig. 5). Recently, new developments in the optics have led to the creation of new generation of wide angled endoscopes with smaller diameters but providing better quality images. The 0° endoscope provides all of the imaging needed to perform major steps of any endoscopic procedure. Its optics allows new-complete exposure of most of the field and pathology. However, the extent of visualization under the 0° endoscope is limited by its optical capabilities. Practically, in cholesteatoma surgery, once cholesteatoma resection under the 0° endoscope is deemed complete, it is replaced with the angled 30° or 45° endoscopes. By advancing the angled endoscope and rotating it clockwise and counterclockwise direction along its longitudinal axis, all middle ear recesses are visualized, and any hidden pathology can be detected and removed. Cholesteatoma resection is considered

Fig. 3: Standard otologic instruments set used by otologists

Fig. 4: KARL STORZ HOPKINS Tele-Otoscopes auto­

in all regular microscopic ear surgery. Selection from plester basic set for ear micro surgery

clavable. (a) 30° endoscope; (b) 0° endoscope; (c) 70° endoscope; (d) 45° endoscope. These otoendoscopes are 3 mm in diameter

Source: KARL STORZ GMBH & Co. KG, Mittelstraße 8, D-78532 Tuttlingen, Germany

136 Otology and Lateral Skull Base

Fig. 5: Schematic drawing of the sinus tympani (ST) and pyramidal eminence area showing the field of view of different angles endoscopes. It explains the degree of visualization each endoscope can provide

complete only after a final survey with the angled endoscopes is completed, confirming absence of pathology. A 70° endoscope may also be used in this examination; however, in most cases, the information obtained by the 30° or 45° lens is sufficient to identify any residual pathology.13-17 b. Instruments: The development of special equipments and instruments for EES is based on the International Working Group on Endoscopic Ear Surgery (IWGEES) for more than 15 years of experience performing endoscope-assisted and/or exclusive EES. Therefore, adapting and refining regular micro-instruments to include longer, more slender shafts with single or double curvatures and smaller microtips have been essential for EES. In addition, major innovation of highly sophisticated equipments, such as Xenon light sources, high-resolution cameras and monitors, digital processors, documentations, lens irrigation systems, have all complemented the advances in endoscopic technology and stimulated the creation of dedicated endoscopic equipment and micro-instruments specially designed to fulfill the unique requirements of EES.   Practically, endoscope-assisted and fully EES will require both the standard otologic microinstruments, familiar and used by any otologist, and the specially modified and newly designed EES instruments adapted for exclusive work under angled endoscopes. Specially designed and adapted micro-endoscopic instruments provided by multiple different companies were used. Different forceps with variable curvatures and longer 10 cm working length are now available. Multiple curettes and dissectors single or double curved, right or left, long or short all designed strictly to facilitate working with the 30° and 45° angled endoscopes. The suction cannulas 10 cm in length had to be modified with curved tip angled 90° and with different diameters of 0.8, 1.0, 1.2 and 1.6 mm. All suction cannulas are of Luer-lock type to be attached to the

Fisch adaptor. A new rotatory adaptor is also used to facilitate rotation of the curved suction.   Because of the growing indications for the exclusive endoscopic surgery, and because major steps are performed under angled endoscopic control the need to modify more instruments to adapt for the angled vision endoscopic surgery (30° and 45°) proved essential. The IWGEES has worked extensively to create a highly specialized instrument set specially designed for EES (Figs 6 A to H). The new IWGEES set of instruments focusing on new details and major modifications.   More instruments specially adapted for EES are now created. Curvature and curved forceps are now in process to improve surgical manoeuverability. We are also working on miniaturization and modification of some of the already existing instruments in progress to adapt for EES. Yet, it is important to realize that once the instruments acquire curved shafts, the instruments will acquire working direction, i.e. right, left and backward. To facilitate

Fig. 6A: New instrument set for endoscopic ear surgery according to the International Working Group on Endoscopic Ear Surgery (IWGEES). Courtesy: KARL STORZ GMBH & Co. KG, Mittelstraße 8, D-78532 Tuttlingen, Germany

The Technique of Otoendoscopy for Cholesteatoma Surgery 137

Fig. 6B: Newly invented suction cannulas, straight, with angled tips of different angulations and lengths. They are of different diameters ranging from 0.8 mm to 1.6 mm; and length 10 cm. All are Luer-lock to be mounted on the Fisch adaptor or the turning adaptor. The need for a rotating adaptor is essential for easy manipulation of cannulas with angled tips. The large choices of diameters for these reusable cannulas provide extra comfort for surgeon to choose the optimum instrument for the task

Fig. 6C: Incorporating suction into the shaft of endoscopic micro-instruments is a major modification that will help the single handed surgeon to overcome bleeding while dissecting or manipulating tissues and holding the endoscope with the other hand. Round cutting knife, diameter 3 mm, with suction shaft easy to handle due to rotatable tubing connector, length 19 cm

Fig. 6D: Set of four endoscopic fine-cupped forceps, working length 10 cm. Strongly curved. Direction: right, left, backward 90° and upward 45°

Fig. 6E: Set of fine sharp hooks and elevators 90°, all with strongly curved shaft and of different directions: right, left and backward. The presence of the curve on the shaft of the instrument mandates the need for different directions, therefore, the newly designed endoscopic instruments handles are marked to allow easy identification of the direction of each instrument: (1) marking for right; (2) markings for left and (3) markings for backward. These marks on the handle avoid confusion and facilitate handling of the right instrument Courtesy: KARL STORZ GMBH and Co. KG, Mittelstrasse 8, D-78532 Tuttlingen, Germany

138 Otology and Lateral Skull Base

Fig. 6F: Ear hooks, sharp, 90° right, left and backward with strongly curved shaft

a

b

Fig. 6G: Newly designed endoscopic instruments: (a) Elevators 90° right, left and backward with strongly curved shaft; (b) the presence of the curve on the shaft of the instrument mandates the need for different directions. These elevators enable atraumatic dissection of the cholesteatoma matrix from over vital middle ear structures

Fig. 6H

The Technique of Otoendoscopy for Cholesteatoma Surgery 139

a

b

c

Fig. 6H: Set of ear curettes of different sizes with bent shaft to facilitate working under angled vision endoscope. Single end curette with curved shaft; double ended curette with 90° curved shaft and the standard house double ended curette. (a) Double ended 90° curved shaft cleaning the anterior epitympanic recess; (b) Double ended 90° curved shaft cleaning the under surface of the scutum transmastoid; (c) Single ended curved curette cleaning the under surface of the scutum transcanal Figs 6A to H: The new IWGEES instrument set illustrating the new details and major modifications

handling of instruments of different direction, handles are now marked according to the direction of the instrument tip, i.e. one mark for right sided, 2 marks for left sided and 3 marks for backward tip (Fig. 6E). The newly introduced IWGEES endoscopic surgical set, specially designed for EES, has proved its efficacy because of perfect maneuverability therefore widened the indications and significantly proved reliability. It includes sets of curved shaft dissectors and sharp hooks, set of curved suction cannulas, set of curved curettes and set of curved cupped forceps with 10 cm working length. Finally, incorporating suction into the instrument shaft is considered one of the major modifications that facilitate dissection with single hand while the other hand of the surgeon holding the endoscope. Best example is the round cutting knife with suction shaft. To illustrate the use of new instruments during EES, multiple endoscopic snapshots are presented in Figures 7A to P. c. Advanced new technologies used in otology surgery: Surgery was performed under video-endoscopic control using the three-chip cameras, and recently the high definition fully digital cameras produce excellent quality images and feature automatic controls over color, exposure, white balance, and digital contrast enhancement. The image 1TM supplied by Karl Storz instantly converts optical images to digital with improved imaging on all digital recording and display devices. It offers the resolution and light sensitivity necessary for the highest digital image quality (Fig. 8). Illumination was

provided using Xenon light source and connected with a fiber-optic light cable (Karl Storz, Germany). The different types of light sources (halogen, xenon, LED) offer light of varying brightness. Xenon is now currently preferred. The endoscopes and light cables were immersed totally in 2% glutaraldehyde (Cidex) for 20 minutes, followed by thorough washing with sterile water. Recently, because all the new Hopkins Storz endoscopes are autoclavable, all scopes are now sterilized using autoclave. The camera was wrapped with an autoclavable cover. High definition LCD screen monitors display the camera image during the entire endoscopic procedure. It should be placed in direct line of view of the surgeon. The digital documentation systems “AIDA compact” HD (Advanced Image and Data Archiving) provide convenient image, video and audio archiving of important stages and results of a procedure for patient and scientific documentation. It ensures a continuous information flow from the operating table to the patient files and also captures high quality images (Fig. 9).   Microdrills are used to perform different acts during middle ear surgery in combination with different sizes curettes. For EES, the pen-style, compact, powerful, lightweight, highperformance microdrills provide the balance and maneuverability that enable the surgeon to work in tight spaces. Also, the microdrill’s attachments are tapered and angled to provide improved visibility of the cutting or diamond burrs at its tip during surgery (Fig. 10).

140 Otology and Lateral Skull Base

Fig. 7A: Right ear view using 30° endoscope. Backward sharp hook (B.Hook) cutting adhesions between the stapes (St) and the facial nerve (FN). Notice the lateral semicircular canal (LSSC) and the scutum (Sc)

Fig. 7C: Right ear showing transmastoid endoscopic view using 30° scope, 3 mm diameter. Double ended curette, 90° curved shaft while cleaning the under surface of the lateral attic mass. Head of malleus (Mal). The strongly curved curette allows the surgeon to remove pathology in deep very difficult to reach spots

Fig. 7B: Right ear view using 30° endoscope. Right elevator (R. Elv) dissecting granulation (*) and cholesteatoma from over the facial nerve (FN) and cochleariform process. Notice promontory (P), the stapes (St) and the scutum (Sc)

Fig. 7D: Right ear showing transmastoid endoscopic view using 30° scope, 3 mm diameter. Left cupped curved forceps removing granulation (*) from the anterior epitympanic recess (Mal: Head of malleus; LSSC: Lateral semicircular canal)

The Technique of Otoendoscopy for Cholesteatoma Surgery 141

Fig. 7E: Right ear showing transcanal endoscopic view using 30° scope, 3 mm diameter. The curved suction cannula removing cholesteatoma (*) from the under the surface of the body of incus (Mal: Head of malleus; FN: Facial nerve; EAC: External auditory canal)

Fig. 7G: Left posterosuperior retraction pocket cholesteatoma. The round cutting knife with suction shaft used to dissect the tympanomeatal flap (Ty Mt Fl) is seen retracting the meatal skin and entering the middle ear (*). Whitish cholesteatoma matrix seen in the retrotympanum (EAC: external auditory canal Pm: Promontory)

Fig. 7F: Right sided sharp hook with a strongly curved shaft used to remove the necrosed long process of incus

Fig. 7H: Right ear view using 30° endoscope. Curved suction cannula cleaning the sinus tympani (ST). Stapes head (St. H) is seen attached by the stapedius tendon. (FR: Facial recess; Sc: Scutum; EAC: External auditory canal; Ch T: Chorda tympani remnant Rw: Round window)

142 Otology and Lateral Skull Base

Fig. 7I: Left ear view using 30° endoscope. Left curved fine cupped forceps with 10 cm working length used to remove granulation tissue (*) from over the neck of the malleus (Ch T: Chorda tympani; EAC: External auditory canal; MH: Malleus handle)

Fig. 7J: Right ear view using 30° endoscope. Left curved fine cupped forceps with 10 cm working length removing granulation tissue from over the sinus tymapni (ST). Stapes head (St. H) attached by the stapedius tendon (FR: Facial recess; Sc: Scutum; EAC: External auditory canal; Tymp M F: Tympanomeatal flap)

Fig. 7K: Right ear view using 30° endoscope. Single endded stronge curved shaft curette (curette SE) used to clean the undersurface of the scutum (Sc) (EAC: External auditory canal; Tymp M F: Tympanomeatal flap)

Fig. 7L: Right ear view using 30° endoscope. Sharp ear hook left sided with strongly curved shaft (L crv Hk) removing granulation tissue from over the sinus tymapni (ST). Stapes head (St. H) attached by the stapedius tendon (St. T); Facial recess (FR); Scutum (Sc); tympanomeatal flap (Tymp M F)

The Technique of Otoendoscopy for Cholesteatoma Surgery 143

Fig. 7M: Right ear view using 30° endoscope. Left curved cupped forceps with 10 cm working length removing granulation tissue (*) from over the sinus tymapni (ST). Stapes head (St. H) attached by the stapedius tendon; facial recess (FR); facial nerve (FN); scutum (Sc); external auditory canal (EAC); tympanomeatal flap (Tymp M F)

Fig. 7N: Left ear view using 30° endoscope. Double

Fig. 7O: Right ear view using 30° endoscope. Right dissector with strongly curved shaft dissecting cholesteatoma matrix from over the facial nerve in the area just behind the cochleariform process

Fig. 7P: Right ear view using 30° endoscope. Long curved

ended strongly curved curette used to clean the anterior epitympanic recess. Notice the double approach surgery as the endoscope is placed transcanal while the curette is passing transmastoid

suction cannula introduced into the orifice of the Eustachian tube (EAC: External auditory canal; St. H: Stapes head; P: Promontory; Tymp M F: Tympanomeatal flap)

Figs 7A to P: Multiple snapshots are presented during endoscopic ear surgery

144 Otology and Lateral Skull Base

Fig. 9: Photo-documentation tower and monitor mounted on a mobile videocart (KARL STORZ, Germany). The cart can be easily customized to any given requirements with a high-definition digital monitors and data management and documentation; light source and video printer. The video monitor is placed on the upper shelf in the surgeon's direct line of vision. Also, digital photo-documentation and DVD recording (STORZ AIDA™ compact system) provide higher resolutions and higher data storage capacity. Sterile, ergonomic operation via touch screen, camera head buttons and/or footswitch

Fig. 8: The image 1™ supplied by KARL STORZ three-CCD chip full digital high definition camera head, maximum resolution 1929 ´ 1080 pixels, with integrated image processing module provides the resolution and light sensitivity necessary for the highest digital image quality

  Other new equipments are also used to facilitate working exclusively under endoscope. The Piezosurgery is specially designed for bone dissection manufactured by Mectron18 Piezosurgery. Although it does not replace the micromotors bone drilling, it offers the state of the art in bone surgery. The piezoelectric ceramic disks contained in the Piezosurgery. Medical handle transmit the

micro vibration to special inserts designed to each surgical technique. It has the advantage of minimal damage to the soft tissue, maximum surgical precision and blood-free surgical site and maximum intraoperative visibility. The wide range of surgical inserts makes it easy to use in different specialties including otology and EES (Fig. 11).   Similarly, VesaliusTM (Telea Electronic 19 Enginee­ring) is a special monopolar and bipolar output device that enables the surgeon to perform surgery with an extremely delicate approach and respect of both tissues and biological structures. The name Quantum Molecular Resonance (QMRTM) comes from the particular way the energy is transferred to the biological tissue in the

The Technique of Otoendoscopy for Cholesteatoma Surgery 145

Fig. 10: Karl Storz unidrive S III ENT consol supplied with angled hand-pieces perfectly designed to adapt manipulation during endoscopic ear surgery

Fig. 11: Piezosurgery medical manufactured by mectron medical technology. The state-of-the-art in bone surgery. Wide range of inserts are used for each type of surgery Source: www.piezosurgery.com



Fig. 12: VESALIUS bipolar coagulation/cutting device. It is a molecular resonance generators, an evolution compared to the traditional electro- or radio-surgical units on the market; VESALIUS® works with a special patented spectrum of frequencies for any function used and for both outputs (monopolar and bipolar). Special set of electrodes designed for endoscopic middle ear surgery, viz. needle electrode and spoon electrode. Vesalius® is a patented product by Telea Electronic Engineering Source: www.vesalius.it

form of high frequency electrical fields that interact with the tissue itself. It is very important to underline that the cut is not a consequence of the high heat produced in the tissue, as happens for the standard electro- or radio-surgical units, but it

is caused by the breakage of the molecular bonds and it is therefore obtained without temperature raise. In fact, the temperature rise is very modest about 63°C sufficient to trigger the coagulation via protein denaturation process. It is supplied with different set of middle ear probes specially designed for endoscopic middle ear surgery to allow fashioning of the tympanomeatal flap and possible dissection of cholesteatoma from over ossicles and epitympanic compartments (Fig. 12). LASER: Mention must be made of different types of LASERS [viz. argon, yttrium aluminum garnet (YAG), neodymium and carbon dioxide]. Each type of LASER has got certain advantages over the other in term of precision, penetration and hemostatic properties. It is a very useful tool during EES because of precision and bloodless field it yields during extirpation of disease.20

SURGICAL TECHNIQUES During the primary surgery and after complete cleaning of cholesteatoma using the operating microscope, the endoscopes were used to verify and detect any epidermal remnant left inadvertently in areas that are difficult to visualize with the operating microscope. The following areas were specially inspected in the following order: facial recess, ST, anterior epitympanic recess, Eustachian tube and hypotympanum. In case any remnant was detected, it was removed using endoscopic guided surgery.

146 Otology and Lateral Skull Base We have consistently used the endoscope as a complementary tool to the microscope since 1995 but only at the end of the microscopic procedure when it was thought that complete eradication of disease had been achieved. Verification of cholesteatoma removal proved possible through the magnified panoramic views obtained by the endoscopes.3 On detection of any cholesteatoma remnants, precise excision could be performed by using fine endoscopic techniques under high resolution videoendoscopic control. Recently, change of strategy and technique improved markedly our results because endoscope and microscope were used interchangeably throughout the course of surgery. Endoscope was actively employed from the beginning of the eradication phase. While using the microscope, whenever the surgeon encounter cholesteatoma extending into any recess or under bony ridge, he shifted to the angled vision endoscope (30º or 45º according to how deep the extension is) and continues the dissection using the newly angled instruments to achieve complete eradication without extra healthy bone only for the sake of visualization. This laid down the basis of functional EES. After achieving total removal of the cholesteatoma matrix using combined technique, such as the transcanal and transmastoid approach, underlay myringoplasty using temporalis fascia graft was done. If there was any defect in the medial border of the scutum, complex repair using fashioned cartilage and/or bone pâté/autograft was performed before placing the graft. The malleus and incus were usually removed when severely eroded, but whenever they were found intact, surgeons could reuse them after meticulous cleaning from any surrounding pathology. In their experience, the reuse of intact ossicles after thorough cleaning did not influence the rate of cholesteatoma recurrence.3 Regarding the second look operations, they were performed with a small, 2 cm incision, post-auricular approach and a limited tympanomeatal flap; and then endoscope was passed transmastoid and transtympanic to rule out recurrence.3,21

CONCLUSIONS The ability of endoscopes to peer into the recesses of middle ear and mastoid cavity proved without doubt its usefulness. The use of endoscope achieved significant higher degree of control over the disease and dramatically reduced the incidence of cholesteatoma recurrence particularly in those hidden recesses such as the ST. Therefore, otoendoscopy has made functional EES our new current standard approach. Furthermore, the use

of endoscope, whether exclusive or as an adjunct to the microscope, not only showed significant improvement in the management of difficult cases, but should be considered a major tool that did improve significantly our results and hence the decision-making of the surgeons. More CWU tympanomastoidectomies are now performed and less second stage surgery is now indicated. Even when performed, the use of endoscope significantly decreased the morbidity of the second look procedures. We are now relying on systematic follow-up of suspected cases using diffusion weighted MRI in the assessment of postoperative cholesteatoma.10,22 Finally, endoscopy is technically feasible for the majority of surgeons in terms of both levels of required surgical skills and accessibility to new equipments. We recommend that ear endoscopy training should start early and be included in all residency training programs. Also, endoscopic surgery should be considered in all ear and temporal bone dissection courses.

REFERENCES 1. Magnan J. The value of endoscopy in otology and neurotology. Otol Jpn 2003;13(3):163-73. 2. Portmann M. The choice of techniques for the surgery of chronic otitis media with cholesteatoma. J Laryngol Otol. 1985;99:533-7. 3. Badr-El-Dine M. Value of ear endoscopy in cholesteatoma surgery. Otol Neurotol. 2002;23:631-5. 4. Thomassin JM, Korchia D, Doris JM. Endoscopic-guided otosurgery in the prevention of residual cholesteatoma. Laryngoscope. 1993;103:939-43. 5. �������������������������������������������������������������� Presutti L, Marchioni D, Mattioli F, et al. Endoscopic management of cholesteatoma: our experience. J Otolaryngol Head Neck Surg. 2008;37(4):481-7. 6. Ozturan O, Bauer CA, Miller CC, et al. Dimensions of the sinus tympani and its surgical access via a retrofacial approach. Ann Otol Rhinol Laryngol. 1996;105:776-83. 7. Abdel Baki F, Badr-El-Dine M, El Saiid I, et al. Sinus tympani endoscopic anatomy. Otolaryngol Head Neck Surg. 2002; 127:158-62. 8. ������������������������������������������������������� Ayache S, Tramier B, Strunski V. Otoendoscopy in cholesteatoma surgery of the middle ear. What benefits can be expected. Otol Neurotol. 2008;29:1085-90. 9. Tarabichi M. Transcanal endoscopic management of cholesteatoma. Otol Neurotol. 2010;31:580-8. 10. Migirov L, Shapira Y, Horowitz Z, et al. Exclusive endoscopic ear surgery for acquired cholesteatoma. Primary results. Otol Neurotol. 2011;32:433-6. 11. Badr-El-Dine M. Surgery of sinus tympani cholesteatoma 
endoscopic necessity. Int Adv Otol. 2009;5:158-65. 12. Hinohira Y, Yanagihara N, Gyo K. Surgical treatment of retraction pocket with bone pate: scutum plasty for cholesteatoma. Otolaryngol Head Neck Surg. 2005;133:625-8.

The Technique of Otoendoscopy for Cholesteatoma Surgery 147 13. El-Meselaty K, Badr-El-Dine M, Mandour M, et al. Endoscope affects decision making in cholesteatoma surgery. Otolaryngol Head Neck Surg. 2003;129:490-6. 14. Presutti L, Marchioni D, Mattioli F, et al. Endoscopic management of acquired cholesteatoma: our experience. J Otolaryngol Head Neck Surg. 2008;37:481-7. 15. Ayache S, Tramier B, Strunski V. Otoendoscopy in cholesteatoma surgery of the middle ear. What benefits can be expected. Otol Neurotol. 2008;29:1085-90. 16. Marchioni D, Mattioli F, Alicandri-Ciufelli M, et al. Transcanal endoscopic approach to the sinus tympani: a clinical report. Otol Neurotol. 2009;30:758-65. 17. Badr-El-Dine M, El-Garem HF, Talaat AM, et al. Endoscopically assisted minimally invasive microvascular decompression of hemifacial spasm. Otol Neurotol. 2002; 23:122-8.

18. Piezosurgery medical manufactured by Mectron medical technology. Peizosurgery S.R.L., Via Portobello 12, 16039 Sestri Levante (GE), Italy. www.piezosurgery.com. 19. VESALIUS® MC bipolar coagulation/cutting device. By Telea Electronic Engineering. Via Leonardo Da Vinci, 13 – 36066 Sandrigo – Vicenza – Italy. www.vesalius.it - www.teleamedical.com. 20. Kakehata S, Futai K, Kuroda R, et al. Office-based endoscopic procedure for diagnosis in conductive hearing loss cases using OtoScan Laser-Assisted Myringotomy. Laryngoscope. 2004;114:1285-9. 21. Youssef TF, Poe DS. Endoscope-assisted second-stage tympanomastoidectomy. Laryngoscope. 1997;107:1341-4. 22. Jindal M, Riskalla A, Jiang D, et al. A systematic review of diffusion-weighted magnetic resonance imaging in the assessment of postoperative cholesteatoma. Otol Neurotol. 2011;32:1243-9.

148 Otology and Lateral Skull Base CHAPTER

18

Endoscopic Management of Cholesteatoma RN Patil

APPLIED ENDOSCOPIC

ANATOMY FOR CLEARANCE OF CHOLESTEATOMA

Anatomy of Posterior Mesotympanum— The Retrotympanic Recesses (Fig. 1) Cholesteatoma, retraction pocket and in certain cases, tympanosclerosis are common in the posterior meso­ tympanum. Endoscope facilitates better appreciation of the spaces in the posterior mesotympanum for disease clearance.

Definition: Posterior tympanum lies between the sulcus tympanicus laterally, and the oval and round windows medially and from the facial canal superiorly to the lower lip of round window inferiorly. Retrotympanic recesses1 relationships are shown in Table 1. Space descriptions of corners in retrotympanum are shown in Figure 2 and Table 2.1 Table 1: Retrotympanic recesses relationships

Superior

Inferior

Fig. 1: The left retrotympanic recesses—sketch (Fn: Facial nerve;

Pe: Pyramidal eminence; Pts: Posterior tympanic space; Pr: Promontory; P: Ponticulus; S: Stapes footplate; St: Sinus tympani; Su: Subiculum; Rw: Round window; Ts: Stapedius tendon)

Medial

Lateral

Posterior tympanic sinus (PTS)

Facial recess

Sinus tympani

Vertical facial nerve

Lateral tympanic recess

Fig. 2: The right retrotympanic recesses (ET: Eustachian tube; Fr: Facial recess; Prom: Promontory; PTS: Posterior tympanic space; Py: Pyramid; Pont: Ponticulus; Rw: Round window; LTS: Lateral tympanic sinus; Fn: Facial nerve; S.ty: Sinus tympani; Sub: Subiculum; Hyp: Hypotympanum)

Endoscopic Management of Cholesteatoma 149 Table 2: Space descriptions of corners in retrotympanum1 S. No. 1.

Name of space Facial recess

Location Superolateral

Defined by Jensen

2.

Lateral tympanic sinus

Inferolateral

Proctor

3.

Posterior tympanic sinus

Superomedial

Legent and Espinoza

Medial: Posterior commissure of oval window Superolateral: Facial canal Inferiorly: Ponticulus

4.

Sinus tympani

Inferomedial

Meckel

Superiorly: Ponticulus Inferiorly: Subiculum Laterally: Pyramidal ridge Medially: Promontory

Anatomical Bony Landmarks in the Posterior Mesotympanum • Subiculum: The bony ridge from lower lip of round window to styloid eminence • Ponticulus: The bony ridge from promontory to the pyramidal process • Styloid eminence: Bony projection in the posterior wall of mesotympanum inferior to the pyramidal process where subiculum gets attached • Chordal eminence: The point where the chorda tympani nerve enters the posterior wall of mesotympanum • Chordal ridge: Bony crest between chordal eminence and pyramidal process.

Anatomy of Attic1,2 Boundaries Roof: Floor of the middle cranial fossa (tegmen tympani). Anteriorly, the tegmen slopes downward toward Eustachian tube (ET) while posteriorly, the tegmen remains horizontal. Lateral: Lateral limit is formed superiorly by very hard bone which lacks air cells that extends in a curved manner to the notch of Rivinus, the edges allowing an insertion ring for the lateral inferior portion of Shrapnell’s membrane. Medially, lies the labyrinth capsule. Posteriorly, opens into the mastoid antrum through the aditus.

Boundaries Medial: Facial nerve Superior: Incus buttress (posterior to short process of incus) Lateral: Tympanic annulus or chorda tympani nerve always run medial to the tympanic membrane. Pyramidal eminence, styloid eminence and chordal eminence It is compared to a triangle with the superior angle at the level of fossa incudis and the two sides formed by the chorda tympani and facial nerves.

Attic Classification1 The medial attic space can be divided into two spaces: (1) anterior attic space and (2) posterior attic space. Medial attic space is situated medial to the ossicles inferior to tegmen tympani, lateral and superior to the facial canal and communicates with the antrum. Cog a bony ridge from the tegmen anterior to the head of malleus which divides the space into anterior epitympanic space (AES)/supratubal recess and posterior epitympanic space (PES). The geniculate ganglion forms the floor of AES. Please see Figures 3, 4 and 5 for the endoscopic attic anatomical views.

Applied Anatomy When cholesteatoma involves the AES its removal is made difficult by the presence of adjacent important structures. Endoscope allows us to see directly the structures in the floor of the epitympanum like second part of facial nerve, cochleariform process and the tensor fold (Fig. 6). Figures 7A and B and 8A and B show 45° endoscopic view of posterior tympanotomy after clearance of chole­ steatoma going into the attic and antrum. The enlarged panoramic view of posterior tym­ pa­ notomy is only possible with an endoscope enabling clearance of disease from such areas as undersurface of scutum with ease without much drilling.

150 Otology and Lateral Skull Base

Fig. 3: Endoscopic view of right posterior attic from mesotympanum (Ad: Aditus; CT: Chorda tympani; Fn: Facial nerve; LSC: Lateral semicircular canal; MA: Madial attic; PC: Processus cochleariformis; Stp: Stapes)

Fig. 4: View of right attic from mesotympanum (Ad: Aditus; Inc: Incus body; IOF: Interossicular fold; Mal: Malleus; Lsc: Lateral semicircular canal; MA: Medial attic; Ct: Chorda tympani; Tt: Tensor tympani tendon; Ctt: Canal for tensor tympani tendon; Fn: Facial nerve; St Fp: Stapes footplate; Sta: Stapes head; Py: Pyramid; Pr: Promontory; Rw: Round window)

Fig. 5: Endoscopic view of right medial attic after sac removal (AAW: Anterior attic wall; HOM: Handle of malleus; PC: Processus cochleariformis)

Fig. 6: 45° endoscopic view of right aditus from attic and mesotympanum

Endoscopic Management of Cholesteatoma 151

Fig. 7A: View of right attic from mastoid

Fig. 7B: View of right attic from mastoid (LSC: Lateral

Fig. 8A: View of attic through left posterior

Fig. 8B: View of attic through right posterior tympanotomy (Ant At: Anterior attic; Mal: malleus; Fn: Facial nerve; LSC: Lateral semicircular canal; Pc: Processus cochleariformis; MA: Medial attic; ET: Eustachian tube)

tympanotomy (PT: Tegmen plate)

CHOLESTEATOMA CONCEPTS, APPROACHES AND CLASSIFICATION

Traditional Microscopic Approaches for Cholesteatoma The cholesteatoma sac, which invades every nook and corner of the middle ear, can be managed by:

semicircular canal; Ml. body: Malleus body; Fn: Facial nerve)

i. Modified Radical Mastoidectomy: In this “exteriori­ zation or marsupialization” of the sac is done. But, the disadvantages of MRM are cavity problems, poor hear­ ing and difficulty in using hearing aids. ii. Microscopic Combined Approach Tympanoplasty: In this “excision” of the sac is done by keeping the canal wall intact thus overcoming the above problems of MRM. In CAT, one is able to get a better middle ear depth and so a better ventilation and better hearing.

152 Otology and Lateral Skull Base Also cavity problems can be avoided and one can use hearing aids. But in CAT, the clearance from the hidden areas like sinus tympani is poorer, increasing the risk of residual cholesteatoma. Also more scutum and posterior canal wall needs to be curetted to visualize and clear attic which predisposes to retractions and recurrent cholesteatoma. Therefore, many surgeons have reverted back to MRM, which still remains as the gold standard in the manage­ ment of cholesteatoma.

Role of Endoscope in Management of Cholesteatoma Cholesteatoma begins in the attic or posterosuperior mesotympanum and remains confined to hidden corners (attic and sinus tympani) of the tympanum—early chole­ steatoma. Only much later, it spreads to the aditus, antrum and mastoid—late cholesteatoma. With microscopic tubular straight line transcanal vision, one cannot cross the narrow ear canal into the nooks and corners of the tympanum (viz. attic and sinus tympani). So for microscopic clearance of such early cholesteatomas, one usually has to resort to postaural approach through the mastoid. In contrast, the endoscope offers a direct wide transcanal access to all hidden areas of the tympanum permeatally without opening the mastoid. In late cholesteatomas, when working with the microscope, inside out and outside in mastoidectomy are the two classical approaches necessary to elevate the cholesteatoma sac fully from the hidden areas of the mesotympanum. In contrast, the endoscope offers a better transposterior tympanotomy access for clearance of such late cholesteatoma with preservation of scutum and sulcus tympanicus. Such preservation prevents retraction and recurrent cholesteatoma after CAT.

Endoscope-Assisted Combined Approach Tympanoplasty Endoscopic angled and close-up vision helps in keeping the posterior sulcus tympani intact and clearing the disease from the sinus tympani satisfactorily. Also with endoscopic angled and close-up vision through posterior tympanotomy helps to clear disease even from the undersurface of scutum convincingly. Thus one can keep the scutum totally intact and clear the disease from the attic. Thus endoscopic vision helps in reducing the high incidence of residual cholesteatoma in CAT.3,4 Also preserving more canal wall and scutum helps in preventing retractions and recurrent cholesteatoma. Endoscopic posterior tympanotomy is easier and possible even in small mastoid cavities without much saucerization of the posterior wall of the mastoid cavity. Thus endoscope will help in reviving CAT.

Endoscopic Permeatal Tympanoplasty for Cholesteatoma Microscopic clearance of the initial localized early cholesteatoma in the hidden areas (attic, mesotympanum and sinus tympani) is not possible without creating a mastoid cavity. However, endoscopic angled vision helps in clearing these hidden areas permeatally without opening the mastoid. So one avoids a postaural incision and opening of the healthy mastoid in localized cholesteatomas. Thus if cholesteatoma is confined only to mesotympanum, then it becomes a e-Tympanoplasty and if cholesteatoma is extending to attic, then it becomes a e-Scutumplasty. Thus e-Tympanoplasty and e-Scutumplasty are the two varieties of endoscopic permeatal tympanoplasty for cholesteatoma (EPTC).

Endoscopic Second Look After any closed technique, even in the best of hands and facilities, the risk of residual cholesteatoma in the tympanum is always there. Hence one must plan a second look if there is a doubt about the primary clear­ ance of cholesteatoma. The second look is a mastoidos­ copy if CAT was done or lateral tympanotomy if EPTC was done.

Author’s Approach to Cholesteatoma Preparation Patient’s ear is made dry by, • Wet aural toilet with 1% acetic acid twice a week • Suction toilet: To remove all epithelial debris • Antibiotics: Systemic and topical (using a ribbon wick as conduit) • Removal of aural polyps, if present. This meticulous preoperative suction toilet is the keystone for preparing an ear for facilitating easier eleva­ tion of epithelial sac during surgery. It also helps in reduc­ ing the intraoperative bleeding a prerequisite for one hand endoear surgery.

Preoperative Evaluation Methods: Following methods are used for evaluation. • Otoendoscopy • Pure tone audiometry • X-ray of mastoid • High resolution computed tomography (HRCT) of temporal bone, if indicated.

Aim of Preoperative Evaluation • To see the extent of cholesteatoma (in attic and/or mastoid) • To assess the extent of ossicular destruction • To plan the type of surgery

Endoscopic Management of Cholesteatoma 153 • To counsel the patient about the plan and second look possibilities.

Intraoperative Evaluation • Tympanomeatal flap elevation in localized early cholesteatoma. • Opening the antrum in late cholesteatoma. The extent of cholesteatoma as assessed by both the preoperative and intraoperative evaluation dictates the management strategy. The details of intraoperative evalu­ ation have been discussed under the procedures.

Why the Mesotympanic Work First in all Cases? With endoscopic vision, one can always start with mesotympanic work first in all cases. There are many advantages of starting with mesotympanic work first. • Cholesteatoma clearance starts from three risky and important areas in the posterior mesotympanum, viz. ossicles, facial nerve and lateral semicircular canal • These are dealt with when everything is fresh, viz. surgeon, local anesthetic effect and vasoconstrictive action of adrenaline giving a bloodless field • Once the tympanomeatal flap is elevated, one can see the extent of cholesteatoma around the ossicles. So an early decision about incus separation prevents acous­ tic trauma • As soon as the incus is removed, one is dot on the facial nerve, lateral semicircular canal and stapes. The mobile close-up endoscopic vision helps to clear the cholesteatoma from these risky spots in the early stage itself • Start with an easily elevatable area usually posteroin­ ferior flap. The angled vision provided by the angled scopes and also by tilting of the scope helps to clear the hidden areas, viz. sinus tympani, hypotympanum, protympanum and attic4-8 • In localized early cholesteatoma, one totally avoids entry into the mastoid—EPTC • While doing permeatal mesotympanic work when­ ever the cholesteatoma goes deeper into the aditus or the clearance from the undersurface of the scutum demands more scutal curettage, one can immediately switch to endoscope-assisted combined approach tympanoplasty (e-CAT) • Even in extensive disease we can do a safe MRM as important landmarks identified in the beginning.

the extent of cholesteatoma in the middle ear cleft which correlates and decides the extent and type of surgery. The author proposed to stage the cholesteatoma into five stages as shown in Table 3 and Figure 9. This staging may form a sound basis for the extent of surgery needed in cholesteatoma management.

Instruments Instrumentation The 4 mm nasal endoscopes (0° and 45°) are used for all procedures. The endoscopes are attached to a single chip endoscopic camera and recording device. All the surgeries are performed off the monitor. For stability, it is convenient to support the shaft of scope 1 cm from tip on to the outer ear canal. During drilling, the scope is held at a distance to avoid any inadvertent damage. The angled curettes, bent suctions, curved picks and various shaped elevators are used while working in nooks and corners along with the angled scopes (45°).

Troubleshooting Short otoendoscopes are not preferred as they make instrumentation cumbersome. Furthermore, the narrow field of vision provided by the pediatric scopes is inad­ equate for ear surgery. The endoscope stands hinder the mobility and maneuvering of the scopes and thus affect­ ing the free visualization of key areas.

Anesthesia Most of the surgeries can be performed under local anesthesia with adrenaline (1:30,000 for infiltration and 1:10,000 for surface) to reduce bleeding.

ENDOSCOPIC PERMEATAL TYMPANOPLASTY FOR CHOLESTEATOMA

Surgical Steps The procedural details of EPTC are given as follows: • Incision, tympanomeatal flap and exposure • Clearance of cholesteatoma from the hidden areas— endoscopic vision is a boon • Reconstruction of middle ear • Postoperative problems

Management as per the Staged Extent of Cholesteatoma

Incision, Tympanomeatal Flap and Exposure

As discussed above in the endoscopic approaches, the extent of cholesteatoma dictates the approach for its management. To our knowledge there is no staging of

Anteroinferiorly based tympanomeatal flap should be raised by an incision from 1 o’clock to 5 o’clock in the outer bony canal.

154 Otology and Lateral Skull Base Table 3: Management summary as per extent of cholesteatoma Staging

Extent of cholesteatoma sac

Type of surgical management

Words for patient counseling

I

Only Mesotympanum

e-Tympanoplasty

Repair of drum and ossicles

II

Attic

e-Scutumplasty

Bridge reconstruction

III

Aditus e-CAT

Bridge preservation

MRM

Saucerization

RM

Middle ear removal–lined by skin

Antrum and periantral area Peripheral mastoid cells elevatable as a single sac IV

V

Peripheral mastoid cells not elevatable as a single sac because of tentacles of cholesteatoma Any stage with complications

(e-CAT: Endoscope-assisted combined approach tympanoplasty; MRM: Modified radical mastoidectomy; RM: Radical mastoidectomy)

Fig. 9: Flowchart for endoscopic cholesteatoma manage­

ment (EPTC: Endoscopic permeatal tympanoplasty for cholesteatoma; CAT: Combined approach tympanoplasty; MRM: Modified radical mastoidectomy; RM: Radical mastoidectomy)

• If the incision is given near the annulus with a thought of preserving more of the normal external auditory canal with its skin attached, the following difficulties may be encountered. The flap shreds more easily as it is thin. The manipulation of the endoscope, curette and drill will be cumbersome. Also the placement of graft, ossicles and cartilage can be difficult, all because of narrow outer canal space • When one resorts to a wider tympanomeatal flap nearer the hairline, many advantages are seen. The thickness of the peripheral flap, pressing the flap to anterior canal wall and covering it by aluminum foil prevents shredding of the flap. It gives a better

exposure which is augmented by canalplasty. This wide exposure will give sufficient space for all tympanic work. The wider flap shall be created by using no. 11 blade for incision, as the skin in this area was very thick and is difficult to incise with the circular knife • Anteroinferiorly based flap is preferred as the involvement of hypotympanum is minimal. Wherever the anterior disease becomes inaccessible because of wide thicker flap or anterior bony over­ hang, then a no base flap can be used by completing the anterior incision. This followed by drilling for a canalplasty will give a wide access and more direct vision to all tympanic areas • If e-CAT is planned then only 5 mm wide antero­ inferiorly based tympanomeatal flap is better. This helps in keeping the outer canal skin attached to posterior canal wall preventing retractions postoperatively. Note that in e-CAT, there is no canalplasty, no curettage of the sulcus tympani or scutum. The 5 mm bared deep bony canal is useful to support the reconstruction. In narrower canals as full elevations or canalplasty are not done, sometimes the canal space may be less. Wherever the disease becomes inaccessible because of above factors or anterior bony overhang then a no base flap can be used by completing the anterior incision.

Clearance of Cholesteatoma from the Hidden Areas—Endoscopic Vision is a Boon Hypotympanum Cholesteatoma is less common in the protympanum and hypotympanum. So there is usually a pocket of air coming from the ET lined by mucosa in these areas. It is easier to

Endoscopic Management of Cholesteatoma 155 get a plane of cleavage between mucosa and epithelium starting from this already available air pocket. It is always preferable to start with an easily elevatable area which is usually the posteroinferior flap, enter the air pocket and then start the elevation of the cholesteatoma sac.

Sinus Tympani The sinus tympani can be even up to 10 mm behind the pyramid (Bowdler).9 This makes the microscopic clear­ ance of cholesteatoma from the hidden sinus tympani difficult. High incidence of residual cholesteatoma has been described by various authors in microscopic closed techniques.3,4,8,10 However, with an endoscope one can manage to clear the cholesteatoma from the hidden sinus tympani in all cases without any residual cholesteatoma in this area.11,12 Other studies of microscopic MRM/CAT also corroborate the advantages of endoscope in clearing cholesteatoma from sinus tympani.4,10,12 One study has observed the reduction of residual cholesteatoma from sinus tympani from 42% to 6% at relook.4,13 Three tempo­ ral bone dissection studies compared the accessibility of the blind pockets in middle ear cleft in both canal wall up (CWU) and canal wall down (CWD) temporal bone dissections. They showed that the advantages of endo­ scopic vision of the above blind alleys especially the sinus tympani is far superior to the microscope in both CWU and CWD dissections.9,14,15

Attic Attic is in the straight line axis of the external auditory canal. Scutum is the screen obstructing its exposure. Relevant curettage of the scutum is a boon to the attic vision. In cases where the sac is seen involving only the lateral attic, the cholesteatoma clearance is managed without disturbing the ossicular chain. When choleste­ atoma is adherent to incus or extending medial to the incus, the incudostapedial joint should be dislocated to prevent labyrinthine trauma. Then the incus is shelled out for vision and clearance off the medial attic wall. In cholesteatoma involving the anterior attic nipping, the head of the malleus provides the vision. While doing permeatal mesotympanic work whenever the choleste­ atoma goes deeper into the aditus or the clearance from the undersurface of the scutum demands more scutal curettage one can immediately switch to e-CAT. Note that in e-CAT, there is no canalplasty, no curettage of the sulcus tympani or attic.

Aditus If cholesteatoma sac can be lifted from the aditus, then e-Scutumplasty EPTC can be done. But cholesteatoma is extending inside the aditus, then cortical mastoidec­ tomy is necessary to decide the further course of action whether e-CAT or MRM.

Ossicular Area

Reconstruction of Middle Ear

With the help of endoscopic movie camera type of vision, one can clear the cholesteatoma from the intact mobile ossicular chain and also from the mobile crura and foot­ plate of stapes without producing any sensorineural hear­ ing loss (SNHL). The endoscope helps one to clear the cholesteatoma from all the surfaces of the ossicular chain without any movement of the patient’s head, repeated tilts and focus adjustments like with the microscope. Simultaneously one can visualize the round window reflex because of the same movie camera effect of the endoscope.

Once the sac is elevated and removed completely, ossicu­ lar reconstruction shall be done using patients’ own ossi­ cles and tragal cartilage. Uncompressed sliced gel foam can be used to fill the middle ear. One zero vicryl can be used to prevent adhesions in raw areas. Tragal or conchal cartilage can be used for scutum reconstruction. The size of the graft (tragal perichondrium or temporalis fascia) needed for tympanic membrane reconstruction was measured with crocodile forceps and placed by underlay technique.

Protympanum

Ossicular Reconstruction

The angled vision of the endoscope helped in complete clearance of the protympanum. The authors could visu­ alize the upper ET in almost all their cases with the 45° scope. The close-up vision and good camera helped us to differentiate normal mucosa from cholesteatoma. So we can preserve more mucosa and hence achieve better ventilation. The plane of cleavage between mucosa and epithelium is easier to get in the protympanum as separa­ tion can be started from the already available air pocket.

Drilling a socket in the body of incus or head of the malleus is easier under the microscopic magnification with the two-hand technique. But with practice it is possi­ ble to do the same with direct vision under the top light. The ability to reposition the incus or malleus on the stapes head is similar with microscope or endoscope with a little experience. The added advantage of using endoscope is its mobile movie camera type of vision which helps in moni­ toring the round window reflex simultaneously.

156 Otology and Lateral Skull Base Attic and Tympanic Membrane Reconstruction • In purely mesotympanic cholesteatomas, only tempo­ ralis fascia was needed • In small attic cholesteatomas, composite tragal graft can be used. Because of the angled scopes and angling of the scopes cholesteatoma could be cleared from hidden areas of the attic with minimal curettage, needing lesser reconstruction • In extensive attic cholesteatoma with big scutal defects, one can resort to conchal cartilage and temporalis fascia. When doing both ossicular and scutum reconstructions simultaneously, one should take care that the ossicular reconstruction does not touch the scutum. A part of neodrum should separate both so that ossicular chain mobility is not hindered. To achieve this, the ossicular placement is done last after lifting the neodrum. For all such manipulations, the movie camera type endoscopic vision is a definite advantage. The microscopic vision with two hands is advantageous for graft placement. But with a wide flap and wide canalplasty it is equally the same with endoscopic vision.

Postoperative Problems The four major postoperative problems possible are: (1) residual cholesteatoma, (2) retraction, (3) middle ear ventilation and (4) perforations.

Residual Cholesteatoma It is important for one to follow the sac till the fundus with adequate exposure by curetting the scutum if necessary to avoid residual cholesteatoma in attic area. Also using better quality camera and experience, the incidence of leaving behind residual cholesteatoma can be nullified. In cases for which doubt exists for postexcision of sac, it is always better to plan for second look.

Retraction Many a time, a postoperative retraction may occur in attic area. These postoperative attic retraction could be related to extent of cholesteatoma and quality of scutum recon­ struction. The possible reasons could be as follows: • Lateral attic wall curettage: In extensive attic chole­ steatoma, we have to curette more of scutum which increases the risk of retraction developing. Such a defect must be reconstructed with a well tailored carti­ lage, after a properly fashioned bed is prepared • Ossicular chain: The attic part of the ossicular chain further narrows the attic space. So, whenever we meddle with the attic area while clearing the medial or anterior attic disease, it is safer to remove and reposi­ tion the incus and/or nip the head of the malleus. This

gives better access to clear medial and anterior attic cholesteatoma and creates better space in attic for postoperative ventilation thus preventing adhesions and incident retractions • Medial attic wall mucosa: Care must be taken while elevating the cholesteatoma to preserve the medial attic wall mucosa. Using the close-up and angled vision of the endoscope preserves the healthy mucosa better. Wherever there is unavoidable raw area, it is better to use vicryl to prevent adhesions. In author’s experience, none of the cases where intraoperative vicryl was used developed retraction. Release of tensor tympani fold also helps in better ventilation postoperatively.16 • Scutum reconstruction: The tragal cartilage recon­ struction is better than conchal cartilage reconstruction. There can be higher rate of conchal cartilage reconstruction going in for retractions which are probably due to slipping of cartilage. Such a slippage of the conchal cartilage may be due to the curvature of the cartilage, inability to carve the thin cartilage, no perichondrial support to keep it in place and lastly we may be choosing conchal cartilage to reconstruct bigger defects. The success rate with tragal cartilage is high due to the stiffness of the cartilage, carving of periphery to fit to the scutal defect. Also the extension of the perichondrium from the composite tragal graft tucked under the skin flap helps to stabilize the graft in position.

Middle Ear Ventilation Middle ear ventilation achieved with this technique is very good. The reasons for having satisfactory ventilation may be related to the following factors: • Good all round bony supports • Good vision of ET • Preserving healthy mucosa • Proper graft placement These are described below: • Bony supports: The natural bony shelves are the scutum, anterior buttress, anteroinferior recess of external auditory canal and sulcus tympanicus. Because of the angled endoscopic vision, the author’s team were able to clear the cholesteatoma from under these shelves with minimal curettage. Such preserva­ tion helps to support the graft, gives good middle ear depth resulting in better ventilation and prevention of retraction. Whenever in cholesteatoma clearance such supports are lost, it would be ideal to drill a bony shelf for support. Wherever wide areas of bridge are lost it is worthwhile to augment the defect of scutum and adja­ cent posterior canal wall with cartilage.

Endoscopic Management of Cholesteatoma 157 • Good vision of Eustachian tube: The angled vision with 45° endoscope helps in complete clearance of the protympanum. The author’s team can visualize the upper ET. • Preserving healthy mucosa is like gold: Mucosal pre­­ servation, wherever possible, encourages regrowth of mucosa into adjacent raw areas, thus helping in better ventilation. In early local­ ized disease, more of healthy mucosal areas can be preserved. Also the close-up vision and good magnification provided by the camera helps to differentiate normal mucosa from cholesteatoma. So one can preserve more mucosa. • Proper graft placement: Anterior tucking of graft under the anteroinferiorly based flap and proper stretching of the graft across the above mentioned bony supports prevents sagging and medialization of the graft.

Perforations When central perforations occur, regrafting these perforations and inspection of the tympanum can be done to look for any residual cholesteatoma. In author’s experience, none of the central perforations had residual cholesteatoma which means that the atticoantral disease get converted into tubotympanic.

ENDOSCOPE-ASSISTED COMBINED APPROACH TYMPANOPLASTY

The role of endoscopes in e-CAT is shown in Table 4. • If e-CAT is planned, then 5 mm wide tympanomeatal flap which is based anteroinferiorly is better. This helps in keeping the outer canal skin attached to posterior canal wall preventing retractions postop­ eratively. Note that in e-CAT, there is no canalplasty, no curettage of the sulcus tympani or scutum. The 5 mm bared deep bony canal is useful to support the reconstruction. • In narrower canals, as full elevations or canalplasty are not done, sometimes the canal space may be less. Wherever the disease becomes inaccessible because of above factors or anterior bony overhang then a no base flap can be used by completing the anterior incision. • With microscope, the posterior canal skin has to be elevated fully to do canalplasty and visualize sinus tympani after posterior sulcal curettage. But with endoscopes, all mesotympanic work can be done without elevation of the canal skin. Thus in e-CAT, preserving the outer canal skin avoids bleed­ ing, button holing, canal distortion and recurrent cholesteatoma.

Table 4: Role of endoscopes in e-CAT Tympanomeatal flap Preserving the outer posterior canal skin attached to bony canal Curettage of sulcus tympanicus for sinus tympani clearance Sinus tympani clearance Outer attic wall curettage

Posterior tympanotomy

Posterior tympanotomy even in small mastoid

e-CAT 5 mm from sulcus Need not be elevated

m-CAT Full posterior canal May need to be elevated

Comparison Avoids bleeding, button holing, canal distortion and recurrent cholesteatoma

No curettage needed as angled vision

More curettage needed for sinus tympani clearance Difficult in deep sinus tympani Needed as undersurface of scutum cannot be visualized Sometimes tricky and difficult, as sulcus removed Difficult in m-CAT, may need pressure on island of bony sinus plate

No curettage needed

Superior as angled vision Not needed, as undersurface clearance done transmastoid Much easier as sulcus is preserved Possible in e-CAT

Sinus tympani clearance superior Lesser in e-CAT

Posterior tympanotomy much easier in e-CAT Second look with island of bony sinus plate is dangerous

158 Otology and Lateral Skull Base • With microscope, the posterior sulcus tympani has to be curetted to see and clear the hidden sinus tympani. But angled scopes help to visualize and clear sinus tympani without removal of sulcus overhang. Such preservation prevents retraction and recurrent chole­ steatoma after CAT. • In microscopic CAT (m-CAT), the outer attic wall (scutum) has to be curetted to clear the attic disease. However in e-CAT, attic clearance can be done, even from undersurface of scutum through posterior tympanotomy, without any curetting of the scutum. So while doing permeatal mesotympanic work when­ ever the cholesteatoma goes deeper into the aditus or the clearance from the undersurface of the scutum demands more scutal curettage, one can immediately switch to e-CAT. The vision provided by the endoscope through the posterior tympanotomy to clear the attic with preservation of the scutum is pivotal advantage of e-CAT over m-CAT giving it superior results in terms of residual and recurrent cholesteatoma. • In e-CAT, initially the incus is removed permeatally. The better angled vision into aditus from the mastoid makes the posterior tympanotomy much easier endoscopically. This is because we have a direct vision of lateral semi­ circular canal and horizontal facial from both sides, viz. from mesotympanum and from mastoid. • Posterior tympanotomy is achieved with lesser marsupialization of the sinus plate. Therefore, e-CAT is possible even in a small mastoid.

• Nonhealing drum

Contraindications Yusuf and Poe14 have listed the following as contraindica­ tions for second look mastoidoscopy: • Low lying dura • Dehiscent dural plate • Dehiscent sigmoid sinus plate • Extensive facial canal dehiscence • Aberrant course of facial nerve • Labyrinthine fistula When we see the list of contraindications, we realize that the simple easy second look mastoidoscopy can be very risky with above primary intraoperative findings. That is why Haberkamp12 and Rosenberg7 have stressed on the need of the importance of operation records before venturing on second looks.

Methods

RELOOK

1. Second look open surgery 2. Second look transtympanic endoscopy 3. Second look lateral tympanotomy 4. Second look mastoidoscopy The second look open surgery involves more time, causes more morbidity, is more costly and many patients may not be willing for second look procedures especially when they are asymptomatic and with good hearing.18 With the endoscopes, we can look into the mesotym­ panum by transtympanic endoscopy through a myringo­ tomy incision,19 by second look lateral tympanotomy,7,20,21 and/or by second look postaural mastoidoscopy.7,8,12,13,18

The Need

Second Look Surgical Procedural Steps

The incidence of residual cholesteatoma in CWD micro­ scopic mastoidectomies varies from 5% to 13%.17 The risk of residual cholesteatoma is significantly higher in microscopic CWU procedures varying from 23% to 50%.17 Considering the high incidence of residual choles­teatoma there is a definite indication for second look surgery. Further, with a postoperative CT scan it is not possible to differentiate between residual cholesteatoma, scar tissue or fluid.18,25,26 Thus second look surgery is the only way of looking for and clearing residual cholesteatoma.

• Convincing the patients: Patients were explained about the need for a second look procedure even before planning primary surgery. Postoperatively, the find­ ings of the primary surgery were shown to the patients on the monitor when they came for follow-up and the need for second look was reiterated. • Review: All records of the primary surgery were reviewed including video recording of the procedure before venturing on second look.

Indications • • • •

Graft failure and perforation Doubtful clearance in primary surgery Worsening of hearing in the late postoperative period Postoperative retractions which are deep with narrow neck

Second Look Mastoidoscopy Incision: In second look mastoidoscopy, a small 1 cm incision was put after routine infiltration over the previ­ ous postaural scar given for mastoidectomy. The mastoid bowl was palpated by finger tip or with a 22 G needle and confirmed. Subcutaneous tissue was dissected with no. 11 blade and with the help of gauze. Plane was achieved to visualize the mastoid. Mucosal bands, which had formed,

Endoscopic Management of Cholesteatoma 159 were incised with the blade to enter the posterior tympa­ notomy. Endoscope was passed behind the suction to avoid soiling of the tip and to have clear vision (Fig. 10). Visualization: Skin hook was used to keep the subcuta­ neous plane open. The mastoid cavity, aditus, attic and mesotympanum were inspected for any residual or recur­ rent cholesteatoma. The status of the ossicular reconstruc­ tion of attic, ET and hidden areas were inspected and noted down and recorded from the TV monitor (Fig. 11). Yusuf22 and Hoberkamp23 have suggested certain changes in the primary surgery to facilitate endoscopic second look. Thus removal of the buttress of fossa incudis and creating a wide extended facial recess and removal of the incus and head of the malleus24 will help in better vision of the attic and mesotympanum during the endo­ scopic second look mastoidoscopy. The wound for second look mastoidoscopy required only two sutures and small dressing without any mastoid bandage. Patients were discharged on the same day.

attic. If wide posterior tympanotomy was done, then the aditus and antrum were also visualized. • Clearance of residual cholesteatoma: During a second look if there was a small residual cholesteatoma, it was removed in toto and the defect reconstructed. If the chole­­­­­­­steatoma was extensive, a MRM would be performed.

Conclusion Endoscopic second look mastoidoscopy is mini­ mally invasive requiring only 1 cm incision. So there is lesser morbidity. Also it involves lesser time and is less expensive. Overall it is more patient-friendly, thus patients can be easily convinced for second look procedures. 18 After EPTC, the author do only a second look lateral tympanotomy. But after CAT, the author’s team do a second look mastoidoscopy and if extent cholesteatoma at primary surgery needs, then they do a second look lateral tympanotomy also.

Second Look Lateral Tympanotomy

CONCLUSION

• Incision and tympanomeatal flap: Lateral tympa­ notomy approach was used to visualize the middle ear as it was done in permeatal management of cholesteatoma. Rosen’s incision was made as for routine stapedectomy and an anteriorly based tympanomeatal flap was elevated. • Visualization: All areas of mesotympanum including hidden areas were visualized using angled scopes. Adhesions, if present, were lysed. It was possible to visualize hypotympanum, protympanum, sinus tympani, ossicular reconstruction and all parts of

Today, “endoscope” has emerged as a workhorse in the field of ENT. However, it is still underutilized in middle ear surgery especially in treating cholesteatomas. This discussion throws light into the less explored role of endoscope in otology. Further research may lead us into an era of minimally invasive endoear surgery. For exteriorization or excision of cholesteatoma with the microscope, the two options available are MRM and CAT. The disadvantages with MRM are cavity problems, poor hearing and difficulty in using hearing aids. CAT overcomes the above problems but increases the incidence

Fig. 10: Incision for endoscopic second

Fig. 11: Second look view of attic through right posterior tympanotomy (ET: Eustachian tube; Tensor; ty: Tensor tympani tendon)

look mastoidoscopy

160 Otology and Lateral Skull Base of residual and recurrent cholesteatoma. The close-up, angled and movie camera type of vision helps in better cholesteatoma clearance and preservation of the healthy mucosa. Mucosal preservation gives good ventilation and thus lesser recurrent cholesteatoma. Better vision reduces the chances of residual chole­steatoma. Cholesteatoma begins in the attic and posterosupe­ rior mesotympanum. In many cases, it does not spread to mastoid but remains confined to hidden areas of the tympanum. Microscopic clearance of these hidden areas is not possible without creating a mastoid cavity. The endoscopic angled vision helps in eradication of limited tympanic cholesteatoma from the hidden areas perme­ atally, and reconstructing the minimally accessed middle ear without opening the mastoid—EPTC. Whenever the cholesteatoma goes deeper into the aditus or the clearance from the undersurface of the scutum demands more scutal curettage, one can immediately switch to e-CAT. The vision provided by the endoscope into the sinus tympani with preservation of the sulcus tympani and the vision through the posterior tympanotomy to clear the attic with preservation of the scutum is pivotal advantage of e-CAT over m-CAT giving it superior results in terms of residual and recurrent cholesteatoma.

ACKNOWLEDGMENTS The author is thankful to his sincere post graduates Dr B Karthikeyan, Dr Shivkumar, Dr Mohit Sinha, Dr Vikram Vel, Dr Amal Das and Dr Santosh Patil. They have contributed immensely to this work of endoscopic ear surgery which was a part of their thesis. Some of them have helped in its compliation.

REFERENCES 1. Marchioni D, Molteni G, Presutti L. Endoscopic anatomy of the middle ear. Indian J Otolaryngol Head Neck Surg. 2011; 63(2):101-13. 2. Palva Ramsay H,Northrop C. Color atlas of the anatomy and pathology of the epitympanum. Karger; 2001. 3. El-Meselaty K, Badr-El-Dine M, Mandour M, et al. Endo­ scope affects decision making in choles­teatoma surgery. Otolaryngol Head Neck Surg. 2003;129(5):490-6. 4. Thomassin M, Korchia D, Doris JM. Endoscopic guided otosurgery in the prevention of residual cholesteatomas. Laryngoscope. 1993;103:939-43. 5. Tarabichi M. Endoscopic management of limited attic cholesteatoma. Laryngoscope. 2004;114(7):1157-62. 6. Tarabichi M. Endoscopic middle ear surgery. Annals of Otorhino-laryngology. 1999;108:39-46. 7. Rosenberg SI, Silverstein H, Michael H, et al. Use of endo­ scopes for chronic ear surgery in children. Arch Otolaryngol Head Neck Surg. 1995;121:870-2.

8. Yung MW. The use of rigid endoscopes in cholesteatoma surgery. J Laryngol Otol. 1994;108:307-9. 9. Bowlder DA, Walsh RM. Comparison of the otoendoscopic and microscopic anatomy of the middle ear cleft in canal wall up and canal wall down temporal bone dissections. Clinical Otolaryngology. 1995;20:418-22. 10. Yung MW. The use of middle ear endoscopy has residual cholesteatoma been eliminated? J Laryngol Otol. 2001;115: 958-61. 11. Marchioni D, Mattioli F, Alicandri-Ciufelli M, et al. Trans­ canal endoscopic approach to the sinus tympani: a clinical report. Otology & Neurotology. 2009;30:758-65. 12. Haberkamp TJ, Tanyeri H. Surgical techniques to facilitate endoscopic second look mastoidectomy. Laryngoscope. 1999;109:1023-7. 13. Yussef TF, Poe DS. Endoscope—Assisted second stage tympano- mastoidectomy. Laryngoscope. 1997;107:1341-4. 14. Abdel Baki F, Badr-El-Dine M, El Saiid I, et al. Sinus tympani endoscopic anatomy. Otolaryngol Head Neck Surgery. 2002;127:158-62 15. Patil RN, Vel V. Comparison of the otoendoscopic and microscopic visualisation of the sinus tympani in canal wall up and canal wall down modified radical mastiodectomy in the cadaveric temporal bone (Dissertation). Bangalore:Rajiv Gandhi University of Health Sciences – Karnataka;2007. 16. Marchioni D, Mattioli F, Alicandri-Ciufelli M, et al. Endo­ scopic approach to tensor fold in patients with attic choles­ teatoma Acta Oto-Laryngologica. 2009;129:946-54 17. Karmarkar S, Bhatia S, Saleh E, et al. Cholesteatoma surgery the individualized technique. Annals of Otol Rhinol Laryngol. 1995;104:591-5. 18. Mckennan KX. Endoscopic ‘Second Look’ mastoidectomy to rule out residual epitympanic/mastoid cholesteatoma. Laryngoscope. 1993;103:810-4. 19. Rosenberg SI, Silverstein H,. Willcox TO, et al. Endoscopy in otology and neurotology. American Journal of Otology. 1994;15(2);168-72. 20. Syms MJ, Luxford WM. Management of cholesteatoma: status of the canal wall. The Laryngoscope. 2003;113:443-8. 21. Bottrill I, Poe D. Endoscope-assisted ear surgery. American Journal of Otology. 1995;16(2):158-63. 22. Roden D, Honrubia V, Wiet R. Outcome of residual chole­ steatoma and hearing in mastoid surgery. Journal of Otolaryngol. 1996;25:178-81. 23. Chang C, Chen M. Canal wall down tympanoplasty with mastoidectomy for advanced cholesteatoma. Journal of Otolaryngol. 2000;29:270-3 24. Sheehy JL. Cholesteatoma Surgery: Canal wall down pro­­ cedures. Annals of Otol Rhinol Laryngol. 1988;97:30-5. 25. Rosenberg SI. Endoscopic otologic surgery. Otolaryngologic Clinics of North America. 1996;29(2):291-300. 26. Tierney PA, Pracy P, Blaney SPA, et al. “An assessment of the value of the preoperative computed tomography scans prior to otoendoscopic ‘Second Look’ intact canal wall mastoid surgery”. Clinical Otoloryngol. 1999;24:274-6.

SurgicalSuppurative Technique of Otoplasty Surgical Management of ComplicationsThe of Chronic Otitis Media 161 CHAPTER

19

Surgical Management of Complications of Chronic Suppurative Otitis Media Bachi T Hathiram, Vicky S Khattar

INTRODUCTION The middle ear lies in close relation to various important anatomical structures like the audiovestibular end organs in the inner ear, the middle cranial fossa, the facial nerve, the venous sinuses, etc. and hence the spread of infection beyond the middle ear can result in serious complications. Following the advent of antibiotics, however, the incidence of complications has greatly reduced. Also, advances in diagnostic and surgical techniques have helped to reduce the mortality rate. Complications can occur in acute as well as chronic suppurative otitis media (CSOM).

MODE OF SPREAD OF INFECTION • Spread in continuity: Infection of the middle ear mucosa can spread to the mastoid and result in mastoiditis • Direct spread through bone by erosion or osteitis as in CSOM or acute suppurative otitis media (ASOM) respectively • Venous spread by retrograde thrombophlebitis to the meninges, venous sinuses and brain • Spread via natural preformed pathways and developmental dehiscences like: – Congenital dehiscences of tegmen plate or facial canal – Un-united suture lines such as petrosquamous suture – Round window or oval window – Spread via perivascular spaces of Virchow-Robin intracranially – Occasionally, spread may occur in cases of recurrent CSOM postoperatively due to iatrogenic pathways created by the surgeon like labyrinthine fistula or destruction of dural or sinus plates during surgery. The various complications of CSOM have been given in Table 1.

The diagnosis of these complications is based on history, clinical features, pure tone audiometry and high resolution computed tomography (HRCT) scan of the temporal bone. Once CSOM with presence of complication is diagnosed, there is no role of conservative modality of treatment. The treatment aims to completely eradicate the disease as well as tackle the complication at the same stage in case of extracranial complications, and treatment of the complication first in case of intracranial complications (since this is life-threatening) followed by surgical clearance of the disease. Table 1: Complications of chronic suppurative otitis media Extracranial

Intracranial

Mastoiditis

Meningitis

Acute

Extradural abscess

Catarrhal

Subdural abscess

Coalescent

Brain abscess

Chronic

Cerebral Cerebellar

Mastoid abscess

Encephalitis

Subperiosteal

Otitic hydrocephalus

Subcutaneous

Sigmoid sinus thrombosis

Luc’s abscess Bezold’s abscess Citelli’s abscess Zygomatic abscess Labyrinthitis Serous Suppurative Facial nerve paralysis Petrositis and Gradenigo’s syndrome

162 Otology and Lateral Skull Base

SPECIFIC INVESTIGATIONS

A pure tone audiometric evaluation for the type and degree of hearing loss is mandatory especially since it helps in documentation as well. In all patients of CSOM where complications are suspected or clinically diagnosed, an HRCT scan of the temporal bone with brain cuts is performed to confirm the diagnosis and also detect the extent of destruction caused by the disease. A magnetic resonance imaging (MRI) is required, if intra­ cranial complications are suspected. In the presence of an actively discharging ear, a swab may be sent for culture and antibiotic sensitivity of the causative organism.

Fig. 1: Postaural fistula with cholesteatoma seen through it

Fig. 2: Postaural fistula following spontaneous rupture of a mastoid abscess

ANESTHETIC CONSIDERATIONS

This surgery is performed under general anesthesia.

CONTRAINDICATIONS There are no contraindications as this is a life-saving surgery and performed with a “high-risk” consent for anesthesia.

STEPS OF SURGERY 1. A postauricular Wilde’s incision is taken. If a postaural fistula (Figs 1 and 2) secondary to a spontaneously ruptured mastoid abscess is present, the skin surrounding this fistula is taken in the incision. 2. Subperiosteal flaps are elevated and the mastoid cortex exposed. In patients who have had a mastoid abscess, there may be erosion of the bone of the cortex (Fig. 3). 3. A canal wall down or open tympanomastoidectomy is performed and all disease as well as necrosed ossicles are removed. 4. The dural or tegmen plate (Figs 4 to 6), sinus plate and sinodural angle are checked carefully for bone erosion if seen or suspected on CT scan. 5. In case of Citelli’s abscess (Figs 7 to 10), the mastoid tip is seen eroded in its medial aspect over the digastric ridge. It is from here that the pus tracks along the posterior belly of the digastric muscle into the neck. 6. In case of Bezold’s abscess, there is erosion of the bone at the mastoid tip lateral to the digastric ridge. It is from here that the pus tracks into the neck along the sternocleidomastoid muscle.

Fig. 3: Erosion of the mastoid cortex with granulation tissue in the antrum seen on elevation of the subperiosteal flaps

Surgical Management of Complications of Chronic Suppurative Otitis Media 163

Fig. 4: High resolution computed tomography (HRCT) scan showing erosion of the tegmen plate with evidence of a softtissue density mass within the mastoid antrum suggestive of cholesteatoma

Fig. 5: Intraoperative image of a canal wall down

Fig. 6: High resolution computed tomography (HRCT) of

Fig. 7: Clinical photograph of a child with Citelli’s abscess

temporal bone showing right tegmen plate erosion

mastoidectomy showing dural plate erosion due to choles­ teatoma

164 Otology and Lateral Skull Base

Fig. 8: High resolution computed tomography (HRCT) of

Fig. 9: Computed tomography (CT) scan of the same

Fig. 10: Intraoperative image showing a canal wall down mastoidectomy performed. The ball probe is pointing to the track of the Citelli’s abscess. Note the erosion of the bone medial to the mastoid tip

Fig. 11: Axial view of a high resolution computed tomography (HRCT) scan of the temporal bone, showing erosion of the lateral semicircular canal

7. The incidence of fistulae during the surgery for chronic otitis media together with cholesteatoma has been reported in a wide range in different geographical areas and countries ranging between 2.9% and 12.5%.1 In the case of sensorineural deafness and/or vertigo, there may be erosion of the bony labyrinth (labyrinthine fistula), which needs to be detected and sealed

(Figs 11 to 17). In a study by Faramarzi et al. (2011),2 the commonest site of location of the fistula was the lateral semicircular canal (95.83%). 8. A promontory fistula (Fig. 18) may be present due to erosion of the bone of the promontory. However, this is a rare site of bone erosion, although not unknown.

temporal bone showing bone erosion medial to the mastoid tip

patient (Fig. 7) showing an intracranial abscess

Surgical Management of Complications of Chronic Suppurative Otitis Media 165

Fig. 12: Intraoperative photograph of a large labyrinthine

Fig. 13: Temporalis fascia placed to cover the middle ear

Fig. 14: A second layer of temporalis fascia graft being used

Fig. 15: The larger graft is now used to cover the smaller

Fig. 16: The fistula sealed

Fig. 17: Gelfoam placed over the double layered

fistula secondary to cholesteatoma

to exclusively cover the fistula as a part of the multilayered closure of the fistula

with graft in position

and mastoid cavity including the fistula site as a part of the multilayered closure of the fistula

graft thus resulting in a double layer of temporalis fascia covering the site of fistula

seal to further strengthen it

166 Otology and Lateral Skull Base

Fig. 18: A case of congenital cholesteatoma

Fig. 19: Intraoperative image showing erosion of the sigmoid

Fig. 20: High resolution computed tomography (HRCT) of

Fig. 21: Intraoperative image showing erosion of the bony

9. A perisinus abscess requires to be drained. However, a sigmoid sinus thrombus (Fig. 19) is not removed (unlike the earlier practice of removal of clots). 10. It has been reported that the frequency of facial nerve paralysis in chronic otitis media ranges from 0.16% to 5.1%.3-5 An erosion of the bony fallopian canal needs to be detected (Figs 20 and 21) and the nerve which

is edematous and traumatized by the dual pathologies of the disease process and the ischemia due to compression of the edematous nerve in the rigid bony canal, needs to be released from the compressive forces by decompression. However, in the presence of infection the nerve sheath is never slit since it is a protective barrier against the toxins.

with erosion of the promontory

temporal bone showing erosion of the bony facial canal

plate with the sinus exposed. The sinus appears blue and is compressible, which indicates a patent sinus. A thrombosed sinus on the other hand appears pale and is noncompressible

facial canal with granulations over the facial nerve

Surgical Management of Complications of Chronic Suppurative Otitis Media 167

Fig. 22: Intraoperative image showing erosion of the bony facial canal with granulations over the bare facial nerve

Fig. 23: Intraoperative microscopic image showing granulations over the stapes footplate

12. The mastoid cavity is covered with a temporalis fascia graft and a meatoplasty is performed to aid in adequate ventilation, drainage and healing of the cavity.

ACKNOWLEDGMENTS The authors are thankful to the Dean, TN Medical College and BYL Nair Charitable Hospital for granting permission to publish this chapter.

REFERENCES Fig. 24: Granulations removed in the same patient as in Figure 23, to reveal a defect in the anterior part of the stapes footplate

11. Granulation tissue and cholesteatoma are completely removed from the middle ear and mastoid cavity. Care is taken when removing the disease from over vital structures such as the facial nerve (Fig. 22), stapes footplate (Figs 23 and 24), a labyrinthine fistula, eroded dural or sinus plate region, etc.

1. Manolidis S. Complications associated with labyrinthine fistula in surgery for chronic otitis media. Otolaryngol Head Neck Surg. 2000;123(6):733-7. 2. Faramarzi AH, Heydari ST, Rusta M. The prevalence of labyrinthine fistula in chronic otitis media surgery in Shiraz, Southern Iran. Iran Red Crescent Med J. 2011;13(8):582-5. 3. Pollock RA, Brown LA. Facial paralysis in otitis media. In: Graham MD, House WF (Eds). Disorders of the Facial Nerve. New York: Raven Press; 1982. pp. 221-4. 4. Savić DL, Djerić DR. Facial paralysis in chronic suppurative otitis media. Clin Otolaryngol Allied Sci. 1989;14(6): 515-7. 5. Kangsanarak J, Fooanant S, Ruckphaopunt K, et al. Extracranial and intracranial complications of suppurative otitis media. Report of 102 cases. J Laryngol Otol. 1993;107(11):999-1004.

CHAPTER

20

Tympanosclerosis: Surgery and Hearing Results Milan Stankovic

INTRODUCTION Tympanosclerosis is an irreversible final stage of pathological process in the middle ear resulting in predominantly conductive hearing loss, without evidence of resolution of the sclerotic changes with time. Cassebohm (1734) was the first to mention this middle ear disease, while Von Troltsch (1873) introduced the term tympanosclerosis. It was nearly forgotten until 1960 when some pathological and clinical studies on tympanosclerosis have been carried out.1,2 Tympanosclerosis is an insidious disease and its incidence is higher than that reported in the literature; the sex distribution between males and females is about 1.7:1, with the maximum number of cases in those who are aged 21 years to 40 years1,2 (Figs 1 to 4). Tympanosclerotic changes vary in size, from small up to involvement of the entire tympanic cavity. They represent avascular dense layers of collagenous fibrous tissue

A

covering and replacing the mucosa of the middle ear cavity with hyaline degeneration and calcification.3 The cause of tympanosclerosis is insufficiently known. Many hypotheses exist, such as: a sequelae of severe acute otitis media, stagnation of secretion into the mucosal fold, disordered fibrogenesis during healing following longstanding inflammation, immunological basis and degenerative processes in otitis media. Recently, other factors have been suggested—osteopontin, human leukocyte antigens, interleukin-6 and hypercalcemia.4-9 Few studies have stated different sites of tympanic membrane involvement by tympanosclerotic plaque, what means that tympanosclerosis does not have any predilection. Inferior quadrants of tympanic membrane were the mainly-involved areas by tympanosclerotic plaques in the author and associates’ patients.1,11 There is no direct relationship between extent of tympanosclerosis and severity of conductive hearing loss. On the other side, sensorineural hearing loss in

B

Figs 1A and B: Otoscopy of tympanosclerosis. Tympanosclerosis with perforation, extensive tympanic tympanosclerosis

Tympanosclerosis: Surgery and Hearing Results 169

A

B Figs 2A and B: Computed tomography. Normal contralateral temporal bone, tympanosclerosis of tympanic membrane (*), and mastoid (**)

A

B

C

D Figs 3A to D: Scanning electron microscopy of tympanosclerotic plaque. Lamellar structure, compact structure with cavitation, pitted structure and thin lamellas

170 Otology and Lateral Skull Base

A

B

C

Figs 4A to C: Pathohistology of temporal bones with tympanosclerosis. Affection of tympanic membrane, malleus, incus and stapes

tympanosclerosis may occur due to the involvement of the cochlea by hyaline degeneration of the membranous labyrinth. Author and associates did not find the correlation between the degree of hearing loss and the extent of tympanosclerosis. The association of cholesteatoma with tympanosclerosis is also controversial. According to some, it is coincidental, while others reported a definite association between the two. Author and associates had no cases of cholesteatoma associated with tympanosclerosis.1

SURGICAL TREATMENT All the patients undergo clinical examination, radiological assessment of the mastoids and tympanic cavity (Schüller’s view, and CAT scan when needed), pure tone audiometry, middle ear compliance in cases of nonperforated ear drum and examination under microscope. Preoperative assessment is mandatory to define the need for surgery. Indications for surgery are: • Tympanic membrane perforation with/without infection. • Air-bone gap (ABG) at least 20 dB. • Bone conduction at least 40 dB in lower frequencies, and at least 60 dB in higher frequencies. • Stabile local and general condition. Descending bone conduction curve is indicative on potential postoperative decreased discrimination score.

Sensorineural hearing loss, that sometimes accompanies conductive changes, can limit the success of tympanoossiculoplasty and the patient will need hearing aids for communication. Advanced bilateral tympanosclerosis should be carefully judged and evaluated for surgery. Adequate explanation to the patient and realistic expectations are extremely valid to avoid bad hearing improvement in tympanosclerosis. Medical status is especially important in older patients. Coexistent diseases (diabetes mellitus, cardiovascular diseases, etc.) can cause bad surgical results, especially in advanced tympanosclerosis. Disease of small blood vessels can have progressive deterioration of results. Eustachian tube function is difficult to assess and the ability to auto-inflate the middle ear is difficult to see through sclerotic tympanic membrane. Anesthesia risk of any kind is a contraindication for this elective surgery. Some endural procedures, such as repair of tympanic perforation or stapedioplasty can be performed in local anesthesia. Tympanoplasties of various types are performed. The plaque is approached and dissected from the medial aspect of the tympanic membrane by elevating a tympanomeatal flap. Tympanic membrane is reconstructed using perichondrium graft, rather than using temporalis fascia. Overlay tympanic membrane grafting can give lateralization, anterior blunting or squamous epithelium entrapment. So, placement of graft under manubrium and its stabilization

Tympanosclerosis: Surgery and Hearing Results 171 on canal wall is preferable. Perichondrium with cartilage or cartilage palisade offers better long-term results. In cases with attic fixation, malleus head is resected, incus is extracted, modeled and interposed between stapedial suprastructure and manubrium in the same stage and attic is reconstructed with conchal cartilage. Tympanosclerotic plaques, inside tympanic cavity, are removed. No foreign material (absorbable sponge) is utilized to prevent re-adhering. Autologous materials are preferable. In cases with stapes fixation, stapedotomy, with a teflon piston and connective tissue graft around it, is done. Adequate prosthesis length is of utmost importance in tympanosclerosis. Malleus and/or incus fixation should be always considered. Palpation of malleus and observation of incudal displacement is a routine step during surgery. Stretching of chorda tympani, to visualize the oval window, should be avoided in order to prevent taste disturbances. In rare cases, chorda must be resected. Careful removal of tympanosclerotic plaques, using diamond burr to obtain adequate space for prosthesis, is important. Overhanging facial nerve can rarely prevent adequate surgical reconstruction. Fenestra should be always covered by connective tissue to prevent perilymph fistula. Vein graft under prosthesis is an excellent option in tympanosclerosis. Round window involvement by tympanosclerosis should be considered. Postoperative care consists of thorough cleaning of the canal and application of topical antibiotics.

POSTOPERATIVE RESULTS Though surgical therapy of tympanosclerosis is widely used and reported, it is still controversial, especially concerning the choice of surgical technique, staging of operation, ossicular replacing material, stapedial surgery, etc.10-16 The extent and severity of tympanosclerosis is usually revealed intraoperatively, so surgical technique should be adequate to any situation which may arise at operation. Plaque removal is needed in myringosclerosis, but removal of plaques prior to grafting is not always advisable.16 The success rate of myringoplasty is the same as in tympanic membrane repair without tympanosclerosis. There was no statistically significant change from shortterm to long-term follow-up in either air bone gap or hearing threshold. In ossicular attic fixation, ossicular reconstruction with partial ossicular replacement prosthesis (PORP) can gave better results than mobilization of the major ossicles in patients with tympanosclerosis.12

The preoperative bone conduction level provides not only prognostic data, but also information on the mobility of the stapes in tympanosclerosis, and the results depend upon the stapes mobility. Stapedotomy, in cases of tympanosclerotic stapes fixation, is particularly controversial. It is traditionally considered to carry a high-risk of postoperative sensorineural hearing loss. Comparing different operation methods, stapedotomy (piston technique) owned the best effect on hearing recovery than stapedectomy or stapediolysis. The hearing result significantly improved in group without stapes fixation but not in group with fixation. In some studies, patients with fixed stapes treated with stapedectomy displayed good hearing results immediately after surgery, but the ABG deteriorated with time and it is not sufficiently good11,13,16 (Figs 5 to 7). Surgery for total ossicular chain fixation of tympanosclerosis is particularly difficult. LASER surgery can be very helpful in such cases. The need to open the footplate, in cases of total ossiculoplasty for tympanosclerosis, is uncommon.15 This may be accomplished with good improvement in hearing with minimal risk. The author and associates had no such cases (Figs 8 to 10). Obliterative tympanosclerosis can be surgically treated by applying a floating mass transducer (FMT). In extreme cases, creation of third window is needed. The promontory is exposed by a transcanal approach. The third window is made anterior-inferior to the round window; the membranous cochlea is left intact. The FMT is gently pushed into the perichondrium-coated cochlear window21 (Fig. 11). The complications of surgery of tympanosclerosis are anacusis, recurrence, facial palsy, retraction of tympanic membrane, sensorineural hearing loss and perilymph leakage.11,13 Careful surgical technique could result in low rate of complications, as in the author and associates’ study. According to all mentioned references and the data of this study, hearing results of surgery for tympanosclerosis are good, no matter which middle ear structure is predominantly involved. Most of the improvement is obtained in lower frequencies. Long-term results are comparable to short-term results, with slight hearing deterioration (PTA— pure tone average) for stapedial fixation.10-16 Surgical therapy for tympanosclerosis gives hearing results comparable to surgery of chronic otitis with or without cholesteatoma, as reported in other references.19,20 The patients are followed up after 3 months to 6 months (short-term results), and during the fifth year after the operation (long-term results). For long-term study, totally 91 patients were available (24 with tympanic membrane involvement, 59 with malleus and/or incus fixation, and 8 with stapes

172 Otology and Lateral Skull Base

A

B

A

B

C

D

C

D

E

F

E

F

Figs 5A to F: Reconstruction of subtotal tympanic perforation

Figs 6A to F: Incudomalleolar tympanosclerosis: retroau­

with tympanosclerosis: retroauricular approach, incisions and elevation of tympanomeatal flap, drilling of bony bed for the graft, palpation of malleus to determine mobility, placement of chondro-perichondral conchal graft under the manubrium and over bony walls. (M: Malleus; I: Incus; S: Stapes, TM: Tympanic membrane; *: Plaque)

ricular approach, elevation of tympanomeatal flap, palpation of manubrium, incudostapedial disarticulation to prevent inner ear damage, atticotomy, resection of malleus head with nipper, interposition of modeled incus, reconstruction of atticotomy with cartilaginous graft, final position. (*: Plaque;