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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4407_Библиотеки_им_академика_М_И_Перельмана
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SECTION X — Operative Surgery
Figure 79.1. Rosen’s incision for tympanotomy.
Lempert II. Starts from the first incision at 12 o’clock
and then passes upwards in a curvilinear fashion between
tragus and the crus of helix. It passes through the incisura
terminalis and thus does not cut the cartilage. Both mastoid and external canal surgery can be done.
3. postaural (or wilde’s) incision (Figure 79.3).
It starts at the highest attachment of the pinna, follows
the curve of retroauricular groove, lying 1 cm behind it,
and ends at the mastoid tip. In infants and children up to
2 years of age, the mastoid process is not developed and
the facial nerve lies exposed near its exit, and the incision
therefore is slanting posteriorly, avoiding lower part of
the mastoid. Some surgeons prefer to make the postaural
incision in the sulcus (retroauricular groove). Postaural
incision is used for:
(a) Cortical mastoidectomy.
(b) Modified radical and radical mastoidectomy.
(c) Tympanoplasty: when perforation extends anterior to
handle of malleus.
(d) Exposure of CN VII in vertical segment.
(e) Surgery of endolymphatic sac.
Figure 79.2. Endaural (Lempert’s) incision. (A) Incision in the canal
and incisura terminalis. (B) Magnified view of A. Note position of Lempert I and Lempert II incisions.
Lempert I. It is semicircular incision, made from 12
o’clock to 6 o’clock position in the posterior meatal wall
at the bony–cartilaginous junction.
Figure 79.3. Types of postaural incisions. (A) Sulcus incision.
(B) Postaural incision in adults. (C) Postaural incision in infants.
Chapter 80
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Cortical Mastoidectomy
Cortical mastoidectomy, known as simple or complete
mastoidectomy or Schwartz operation, is complete exenteration of all accessible mastoid air cells and converting them into a single cavity. Posterior meatal wall
is left intact (Figure 80.1). Middle ear structures are not
disturbed.
INDICATIONS
1. Acute coalescent mastoiditis (see p. 84).
2. Incompletely resolved acute otitis media with reservoir
sign.
3. Masked mastoiditis.
4. As an initial step to perform:
a. endolymphatic sac surgery
b. decompression of facial nerve
c. translabyrinthine or retrolabyrinthine procedures
for acoustic neuroma.
Figure 80.2 shows the various structures and land-
marks seen after cortical mastoidectomy.
ANAESTHESIA
General anaesthesia.
POSITION
Patient lies supine with face turned to one side and the
ear to be operated uppermost.
STEPS OF OPERATION
1. incision. A curved postaural incision about 1 cm behind but parallel to the retroauricular sulcus, starting
at the highest attachment of pinna to the mastoid tip
(Figure 80.3A).
In infants and children up to 2 years, the incision is
short and more horizontal. This is to avoid cutting facial
nerve which is superficial in the lower part of mastoid
(Figure 80.3B).
Incision cuts through soft tissues up to the periosteum.
Temporalis muscle is not cut in the incision.
2. exposure oF lateral surFace oF mastoid and
macewen’s triangle. Periosteum is incised in the
line of first incision. A horizontal incision may be
made along the lower border of temporalis muscle for
more exposure.
Periosteum is scraped from the surface of mastoid and
posterosuperior margin of osseous meatus. Tendinous
fibres of sternomastoid are sharply cut and scraped down.
A self-retaining mastoid retractor is applied.
Figure 80.1. Cortical mastoidectomy. Posterior meatal wall is left
intact.
3. remoVal oF mastoid cortex and exposure oF
antrum. Mastoid cortex is removed with burr, or gouge
and hammer. Mastoid antrum is exposed in the area of
suprameatal triangle (MacEwen’s triangle). In an adult,
antrum lies 12–15 mm from the surface. Horizontal semicircular canal is identified. Keep in mind the presence of
Korner’s septum which would need removal to explore
the antrum.
4. remoVal oF mastoid air cells. All accessible
mastoid air cells are removed leaving behind the bony
plate of tegmen tympani above, sinus plate behind and
posterior meatal wall in front.
5. remoVal oF mastoid tip and Finishing the
caVity. Lateral wall of the mastoid tip is removed,
exposing muscle fibres of posterior belly of digastric.
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SECTION X — Operative Surgery
Figure 80.2. Various structures and landmarks seen after cortical mastoidectomy.
is closed in two layers. A rubber drain may be left at the
lower end of incision for 24–48 h in case of infection or
excessive bleeding. A meatal pack should be kept to avoid
stenosis of ear canal. Mastoid dressing is applied.
Figure 80.3. Types of postaural incisions. (A) Postaural incision in
adults. (B) Postaural incision in infants.
Zygomatic cells situated in the root of zygoma and retrosinus cells lying between sinus plate and bony cortex
behind the sinus are removed. A finished cavity should
have bevelled edges so that soft tissue can easily sit in
and obliterate the cavity.
6. closure oF wound. Mastoid cavity is thoroughly irrigated with saline to remove bone dust and the wound
POSTOPERATIVE CARE
1. Antibiotics started preoperatively are continued postoperatively for at least 1 week. Culture swab taken from
the mastoid, during operation, may dictate a change in
the antibiotic.
2. Drain, if put, is removed in 24–48 h and sterile dressing done.
3. Stitches are removed on the sixth day.
COMPLICATIONS
1. Injury to facial nerve.
2. Dislocation of incus.
3. Injury to horizontal semicircular canal. Patient will
have postoperative giddiness and nystagmus.
4. Injury to sigmoid sinus with profuse bleeding.
5. Injury to dura of middle cranial fossa.
6. Postoperative wound infection and wound breakdown.
Chapter 81
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Radical Mastoidectomy
Radical mastoidectomy is a procedure to eradicate disease
from the middle ear and mastoid without any attempt to
reconstruct hearing. Posterior meatal wall is removed and
the entire area of middle ear, attic, antrum and mastoid is
converted into a single cavity. All remnants of tympanic
membrane, ossicles (except stapes footplate) and mucoperiosteal lining are removed (Figure 81.1). Eustachian
tube is obliterated by a piece of muscle or cartilage. Aim
of the operation is to permanently exteriorize the diseased area for inspection and cleaning. The radical mastoidectomy is infrequently required these days.
INDICATIONS
1. When all cholesteatoma cannot be safely removed, e.g.
that invading eustachian tube, round window niche,
perilabyrinthine or hypotympanic cells.
2. If previous attempts to eradicate chronic inflammatory
disease or cholesteatoma have failed.
3. As an approach to petrous apex.
4. Removal of glomus tumour.
5. Carcinoma middle ear. Radical mastoidectomy followed by radiotherapy is an alternative to en bloc removal of temporal bone in carcinoma middle ear.
ANAESTHESIA
Mostly, general anaesthesia is given. Local anaesthesia
can be used in selected cases.
POSITION
Same as for cortical mastoidectomy.
Figure 81.1. Radical mastoidectomy. The entire area of mastoid,
middle ear, attic and antrum is exteriorized. Eustachian tube is obliterated and no attempt is made to reconstruct the hearing mechanism.
STEPS OF OPERATION
1. inciSion. Postaural (Figure 81.2) or endaural
( Figure 81.3).
2. retraction oF SoFt tiSSueS anD exPoSure oF MaS-
toiD area. Mastoid area from posterior root of zygoma to
behind the suprameatal triangle and from temporal line
above to the lower part of mastoid tip below is exposed by
elevating the periosteum and the wound retracted.
3. reMovaL oF Bone anD exPoSure oF attic anD an-
truM. With the help of burr, bone is removed from the
area of suprameatal triangle, spine of Henle, root of zygoma to just above the anterior meatal wall, upper part
of superior meatal wall is also removed. This will expose
attic and antrum. Identify the tegmen antri and lateral
semicircular canal.
4. reMovaL oF the “BriDge” anD the ButtreSSeS.
Deeper part of superior osseous meatal wall that bridges
over the notch of Rivinus is removed.
Anterior spine of the notch (anterior buttress) and posterior spine of the notch (posterior buttress) are also removed. This removes the lateral attic wall. The incus and
the malleus are also removed.
5. Lowering the FaciaL riDge. The deeper part of pos-
terior meatal wall that overlies the vertical part of facial
nerve is called facial ridge. It is removed as much as possible within the safety of VIIth nerve so that the mastoid
cavity is freely accessible from the meatus.
6. toiLet oF MiDDLe ear. Remnants of tympanic
membrane with its annulus and sulcus tympanicus are
removed. Middle ear mucoperiosteum along with any
polyp or granulation tissue is removed. Malleus and incus are removed if not already done. Stapes is left intact.
Eustachian tube opening is closed by curetting its mucosa
and plugging the opening with tensor tympani muscle or
piece of cartilage.
7. inSPection oF the cavity anD irrigation. It is
necessary to ensure complete exteriorization of the attic,
antrum and middle ear and mastoid cavity into external
auditory meatus. Any bony overhangs are removed and
cavity smoothened with polishing burr. Finally, it is irrigated with saline to remove any blood or bone particles.
8. MeatoPLaSty. A flap, based laterally at the concha is
raised from posterior and superior meatal wall and turned
into the mastoid cavity to cover the area of the facial
ridge. This helps in the epithelialization of the mastoid
cavity. A piece of conchal cartilage can be removed to enlarge the meatus and to facilitate inspection and access
to cavity.
9. oBLiteration oF the cavity. If mastoid cavity is
very large, it may be obliterated with temporalis muscle
or other soft tissues, taking care that no vestige of disease
(cholesteatoma) is buried underneath.
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SECTION X — Operative Surgery
Figure 81.2. Types of postaural incisions.
10. Closure of Wound. The cavity is packed with ribbon gauze, impregnated with an antibiotic/antiseptic and
the wound is closed with interrupted sutures. Mastoid
dressing is applied.
POSTOPERATIVE CARE
1. dressing. First dressing is done on third or fourth
day. Replace the outer gauze and cotton and look for any
signs of perichondritis or infection of meatal pack.
Second dressing is done on sixth or seventh day when
stitches are removed and meatal pack is changed. Thereafter, change the pack at weekly intervals or leave the
cavity unpacked with regular suction and cleaning till
epithelialization is complete.
2. AntibiotiC. A suitable antibiotic is given for about
a week.
3.
CAvity CAre. Usually, cavity is fully epithelial-
ized in 2–3 months. It should be periodically checked
Figure 81.3. Endaural incision.
(every 4–6 months) in the first year and then annually
for removal of any debris or infection. Any granulation tissue which delays epithelialization is removed or
cauterized.
COMPLICATIONS
1. Facial paralysis.
2. Perichondritis of pinna.
3. Injury to dura or sigmoid sinus.
4. Labyrinthitis, if stapes gets dislocated.
5. Severe conductive deafness of 50 dB or more.
This is due to removal of all ossicles and tympanic
membrane.
6. Cavity problems. Twenty-five per cent of the cavities
do not heal and continue to discharge, requiring
regular aftercare.
Chapter 82
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Modified Radical Mastoidectomy
It is a modification of radical mastoidectomy where as
much of the hearing mechanism as possible is preserved.
The disease process which is often localized to the attic
and antrum is removed and the whole area fully exteriorized into the meatus by removal of the posterior meatal
and lateral attic wall (Figure 82.1).
INDICATIONS
1. Cholesteatoma confined to the attic and antrum.
2. Localized chronic otitis media.
Irreversibly damaged tissues are removed, preserving
the rest to conserve or reconstruct hearing mechanism.
ANAESTHESIA
Mostly general, local anaesthesia can be used in selected
cases.
POSITION
Same as for cortical mastoidectomy.
STEPS OF OPERATION
1. Incision, postaural or endaural.
2. Retraction of soft tissues and exposure of mastoid area.
3. Removal of cortical bone and exposure of antrum
and attic.
4. Steps 2 and 3 are the same as in radical mastoidectomy.
5. Removal of diseased tissue. Cholesteatoma, granulations or unhealthy mucosa is removed. Incus and head
of malleus often require removal, if cholesteatoma engulfs them or extends medial to them. They are preserved if possible. Lateral attic wall is removed to fully
exteriorize the attic.
6. Facial ridge is lowered.
7. Mastoid cavity is smoothened with polishing burr, removing any overhangs and then irrigated with normal
saline.
8. Reconstruction of hearing mechanism. Pars tensa of
tympanic membrane and middle ear, if healthy, are left
undisturbed. If disease extends into middle ear, only
the irreversible tissues are removed. Reconstruction of
tympanic membrane or ossicular chain, if damaged,
can also be done (mastoidectomy with tympanoplasty
operation).
9. Meatoplasty and closure of wound are same as in radical mastoidectomy.
Figure 82.1. Modified radical mastoidectomy. Posterior meatal wall
is removed to exteriorize the diseased area into the meatus and the
hearing mechanism reconstructed.
POSTOPERATIVE CARE
AND COMPLICATIONS
Same as in radical mastoidectomy.
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Chapter 83
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Myringoplasty
Closure of perforation of pars tensa of the tympanic
membrane is called myringoplasty. It has the advantage of:
1. restoring the hearing loss and in some cases the
tinnitus.
2. checking repeated infection from external auditory canal and eustachian tube (nasopharyngeal infection ascends more easily via eustachian tube in the presence
of perforation than otherwise).
3. checking aeroallergens reaching the exposed middle
ear mucosa, leading to persistent ear discharge.
Myringoplasty should be differentiated from type I
tympanoplasty. Though both refer to repair of tympanic
membrane, tympanoplasty entails exposure of the middle ear to inspect the middle ear and also ensure ossicular
integrity.
Myringoplasty can be combined with ossicular recon-
struction when it is called tympanoplasty.
Physiologic principles for middle ear reconstruction
are discussed on p. 31.
CONTRAINDICATIONS
1. Active discharge from the middle ear.
2. Nasal allergy. It should be brought under control before surgery.
3. Otitis externa.
4. Ingrowth of squamous epithelium into the middle ear.
In such cases, excision of squamous epithelium from
the middle ear or a tympanomastoidectomy may be
required.
5. When the other ear is dead or not suitable for hearing
aid rehabilitation.
6. Children below 3 years.
ANAESTHESIA
Local or general, the former is preferred.
Incision for exposure of tympanic membrane depends
on the size of the ear canal; it may be endomeatal, endaural or postaural.
TECHNIQUE
UNDERLAY TECHNIQUE
1. Harvesting the graft, e.g. of temporalis fascia; or peri-
chondrium from the tragus.
2. Preparing the tympanic membrane for grafting. An
incision is made along the edge of perforation and the
ring of epithelium removed. Remove also a strip of
mucosal layer from the inner side of perforation.
3. Inspecting the middle ear. A stapes-type incision is
made and the tympanomeatal flap raised to see the in-
tegrity and mobility of the ossicular chain and to en-
sure that no squamous epithelium has grown into the
middle ear.
4. Placing the graft. Middle ear is packed with gelfoam
soaked with an antibiotic. A proper-sized graft is placed
so that its edges extend under the margins of perfora-
tion all round and a small part also extends over the
posterior canal wall. Tympanomeatal flap is replaced.
An underlay technique has the advantage that the
squamous epithelium is not buried in the middle ear
(Figure 83.1).
OVERLAY TECHNIQUE
1. Temporal fascia or perichondrial graft is harvested as
above.
2. Incision is made in the meatus as shown in Figure 83.2
and meatal skin raised along with all epithelium from
the outer surface of tympanic membrane remnant and
preserved to be used later.
3. Graft placed on the outer surface of tympanic mem-
brane. A slit is made in the graft to tuck it under the
handle of malleus (Figure 83.3).
POSITION
Supine with face turned to one side; the ear to be operated is up.
Graft materials used are:
2. Areolar fascia overlying the temporal fascia
3. Perichondrium from the tragus
4. Cartilage
5. Vein
6. Periosteum
Figure 83.1. Myringoplasty. Underlay technique—fascia graft is under the anterior annulus. It is supported by gelfoam in the middle ear
to prevent medial displacement.
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Figure 83.2. Overlay technique. (A) Incision to raise medial meatal
skin with tympanic membrane epithelium. (B) Placement of graft.
(C) Replacement of skin.
SECTION X — Operative Surgery
3. Patient is seen at 3 and 6 weeks after operation.
4. Complete epithelialization of graft takes 6–8 weeks.
COMPLICATIONS
UNDERLAY TECHNIQUE
1. Middle ear becomes narrow.
2. Graft may get adherent to the promontory.
3. Anteriorly, graft may lose contact from the remnant of
tympanic membrane leading to anterior perforation.
OVERLAY TECHNIQUE
1. Blunting of the anterior sulcus.
2. Epithelial pearls. They are epidermal cysts, when
squamous epithelium is buried under the graft.
3. Lateralization of graft. Graft loses contact from the
malleus handle resulting in conductive loss. It is prevented by tucking the graft under the handle.
OTHER PROCEDURES FOR CLOSURE OF
TYMPANIC MEMBRANE PERFORATION
Figure 83.3. Myringoplasty. Overlay technique—fascia graft lies lat-
eral to anterior annulus onto the anterior bony canal wall. It is placed
medial to malleus handle to prevent lateralization.
4. Meatal skin removed earlier is now replaced, covering
the periphery of the graft.
5. Ear canal packed with gelfoam and then with a small
antibiotic pack.
A modification of the overlay technique is to place
the anterior edge of fascia graft under the annulus after
removing the epithelium from its undersurface. This
prevents blunting of anterior canal which is seen as a
complication of overlay technique.
6. Closure of endaural or postaural incision.
7. Mastoid dressing.
POSTOPERATIVE CARE
1. Stitches are removed after 5–6 days.
2. Ear pack is removed after 5–6 days without disturbing
the gelfoam.
1. SPLintage. It is used in fresh traumatic perforations.
The torn edges of the perforation are carefully everted
under the microscope and splinted with absorbable gelfoam placed in the middle ear through the tear. Smaller
tears can be splinted on the outer surface of the tympanic
membrane with a piece of cigarette paper, gelfilm or silicon sheet.
2. cautery Patching. This is useful in small, longstanding central perforations where the margins have
become epithelialized and chronic. In this procedure,
margins of the perforation are cauterized with 50%
trichloracetic acid to remove the epithelialized edge (or
freshened with a fine pick used for myringoplasty) and
then supported with a cigarette paper moistened with 1%
phenol in glycerine. This procedure can be repeated at
2 weeks interval. Instead of cigarette paper, other material such as steristrip, gelfilm or silicone sheets have also
been used.
3. Fat-graFt MyringoPLaSty. It is also used to close
small perforations. After local anaesthesia, edges of perforation are freshened with 1 mm stapes hook. The inside
of perforation is also scrapped. A small piece of fat harvested from the ear lobule is plugged into the perforation
like an hourglass. Over a time, the fat graft adheres and
closes the perforation.
Chapter 84
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Proof Puncture (Syn. Antral Lavage)
This procedure involves puncturing the medial wall of
maxillary sinus in the region of inferior meatus and irrigating the sinus.
INDICATIONS
1. Chronic and subacute maxillary sinusitis with dual
purpose of: (i) confirming the diagnosis and (ii) washing out the pus.
2. To collect the specimen of the antral contents for culture and sensitivity, or cytological examination to exclude early malignancy.
CONTRAINDICATIONS
Figure 84.1. Antral puncture.
removed and a pack kept in the inferior meatus to control bleeding.
Acute maxillary sinusitis for fear of osteomyelitis.
ANAESTHESIA
In adults, local anaesthesia is preferred. A pack of 4%
lignocaine with adrenaline is kept in inferior meatus for
10–15 min. In children, general anaesthesia is required.
Area of middle meatus should be decongested to open the
maxillary ostium for easy return of fluid.
POSITION
Sitting position is preferred in all adults, when using local
anaesthesia. When using general anaesthesia, patient is
placed in tonsillectomy position.
TECHNIQUE
The lateral wall of inferior meatus is punctured with Lichtwitz trocar and cannula at a point 1.5–2.0 cm from
anterior end of inferior turbinate and near the attachment of concha with lateral wall. Here, the bone is very
thin and can be easily pierced. Trocar and cannula are
directed towards the homolateral ear. The nasoantral
wall pierces with a “crack.” Now remove the trocar and
advance the cannula till it reaches the opposite antral
wall and then withdraw a little. The antrum can now
be irrigated with normal saline at 37 °C with a 20 mL or
Higginson’s syringe (Figure 84.1). Syringing is continued
till return is clear. After the puncture is over, cannula is
DIAGNOSIS OF ANTRAL PATHOLOGY
1. Thin amber-coloured fluid, flowing from cannula immediately on puncture and containing cholesterol
crystals, indicates presence of antral cyst.
2. Blobs of mucopus in washings indicate hyperplastic sinusitis.
3. Presence of foul-smelling pus which easily mixes with
irrigating fluid indicates suppuration. In such cases,
antral wash may be repeated once or twice a week.
POSTOPERATIVE CARE
1. Pack is removed after about an hour.
2. Antibiotics should be given for 5–6 days in cases of
suppuration.
3. Nasal decongestant drops should be used to improve
patency of the ostium.
4. Analgesics may be required for headache or postoperative pain.
COMPLICATIONS
1. Swelling of cheek. This is due to faulty technique. In
this case, cannula lies in the soft tissues over the anterolateral wall of the maxilla and has failed to pierce the
nasoantral wall.
2. Orbital injury and cellulites. If trocar and cannula
pierces the roof of antrum.
3. Puncture of the posterior antral wall. This would
cause swelling in posterior part of cheek.
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