EAR SURGERY

1. EAR SURGERY
Dr Nor Amilah Binti Mohd Ramli
07/01/2020

2. Brief overview of the ear
Types of ear surgery
Incisional approaches to ear surgery
Myringotomy
Tympanoplasty
Mastoidectomy
Stapedectomy
Cochlear implantation

4. Consist of:
Auricle(pinna) - Made of elastic cartilage,
exc at lobule
External auditory canal
Tympanic membrane

5. 3 Ossicles
1) Malleus
2) Incus
3) Stapes
- Footplate of stapes fits into oval window
2 muscles
1)Tensor tympani-pulls the TM inward, protecting it from
excessive movements.
2)Stapedius- Dampen down the intensity of high pitch
sounds

6. 2nerves
1)Chorda tympani
2)Tympanic plexus

7. Opening of auditory Tube (Eustachian tube)
- During swallowing and yawning it opens to equal
pressure in middle ear.

8. It consist of 2parts
Bony labyrinth- SCC, Vestibule, cochlear
Membranous labyrinth- interconnected
sacs and ducts inside the bony labyrinth

9. SCC – superior, posterior and lateral
Vestibule
Cochlear

10. Cochlea
- Divided into 3 channels
Cochlear duct (scala media)- Contains the Organ of Corti
Scala vestibuli- Ends at the oval window
Scala tympani

11. Organ of Corti
– Contains stereocilia & receptor hair cells
– Fluid movement causes deflection of nerve endings
– Nerve impulses (electrical energy) are
generated and sent to the brain

12. The three most commonly used surgical approaches to the middle ear and mastoid
are:
 Transcanal,
 Endaural,
 Postaural

13. Transcanal approach

14. Indications
 Tympanoplasty
Ossiculoplasty
Stapedectomy
Removal of glomus tympanicum
Exploratorytympanotomy
Second look tympanotomy
Repair of round window after rupture

15. Endaural approach
 Commonly used in infants and young children
 Accessibility to epitympanum and postero-superior part of mesotympanum
 Temporalis fascia and tragal cartillage graft can be easily obtained
 faster and less traumatic compared to the postaural approach
 Difficult to gain access to mastoid tip cells

16. Indications
 Tympanoplasty
 Atticotomy and atticoantrostomy
 Congenital and acquired cholesteatoma in the epitympanum
 meatal stenosis
 Excision of osteomas and exostoses of ear canal
 Large tympanic membrane perforation
 Modified radical mastoidectomy

17. Post auricular approach
Indications
 Cortical mastoidectomy
 MRM and radical mastoidectomy
 Combined approach tympanoplasty
 Cochlear implantation
 Facial nerve surgery
 Translabyrinthine removal of acoustic tumour
 Retrolabyrinthine approach to CP angle
 Carcinomaofthemiddleear
 Extensiveglomusjugularetumours
 Rarely,thrombophlibitisarisingfromlateralsinus thrombosis
 Some cases of congenital atresia

18.  The anesthesia is the same as that described for the transcanal approach,
 Additional injection sites are required in the postauricular area

19.  INCISION

20.  Incision in children

21. May involve the tympanic membrane, middle ear cavity, mastoid or inner ear
It may be done for perforation of the eardrum, to facilitate drainage and removed
diseased tissue in cases of infection, to relieve vertigo, or to treat hearing loss
Types of ear surgery:
1) Myringotomy
2) Tympanoplasty
3) Mastoidectomy
4) Stapedectomy
5) Cochlear implants
6) Others- Labyrhintectomy/ Endolymphatic decompression and shunt

22.  Defined as incision of the tympanic membrane and drainage of middle ear
 Creating a surgical opening into tympanic membrane for possible drainage tube
insertion
Indications:-
Acute suppurative otitis media:-
a) With bulged tympanic membrane on the of rupture
b) b) If severe earache persists in a child inspite of conservative treatment, & the child
is restless & is having disturbed sleep.
c) c) Inadequate drainage- small pulsating perforation. d) Acute otitis media with
complication.
Secretory otitis media.
Unresolved otitis media.

23.  Anaesthesia:-
General anaesthesia is indicated in acute otitis media & local anaesthesia in
secretory otitis media & other infections.
In children, general anaesthesia is necessary.

24.  Operation:-
- done under operating microscope.
- Incision is made at the antero-inferior quadrant
- After incision of the drum the middle ear is sucked out through the incision
- Sometimes a grommet (ventilation tube) is inserted to prevent recurrence, which
remains in place so long the Eustachian tube function does not return back to
normal.

26.  Instruments

27.  Complications:
Injury to the ossicles
Injury to the inner ear
Injury to the chorda tympani nerve.

28.  Tympanoplasty means eradication of diseased pathology from the tympano-
mostoid segment in chronic suppurative otitis media & to reconstruct the hearing
mechanism.
 Principles of the operation are:-
1.Complete disease clearance.
2.Preservation of hearing mechanism
3.Preservation of the posterior meatal wall.

29.  There are five types:
 Type I- Simple closure of the perforation.
 Type II-Defect is perforation of tympanic membrane with erosion of malleus.
 Type III- Mallus & incus are removed along with disease clearance.
 Type IV- Only the footplate of stapes is present. It is exposed to the external ear, &
graft is placed between the oval & round window.
 Type V- Is by-passing the fixed stapes & making a fenestra on the lateral
semicircular canal.

33.  This is an operation for the radical clearance of the disease pathology from the
middle ear cleft including epitympanum & mastoid temporal bone, making a
single cavity communicating with the external canal.
 This is for good drainage & for inspection of the operated cavity.
 The ear is made dry & safe.

34.  Mastoidectomy provides an access to remove
1.diseased air cell of mastoid in mastoiditis
2.cholesteatoma
3.granulation tissue in otitis media
 Traditionally, classified as :
1. Simple (cortical) mastoidectomy
2. Modified radical mastoidectomy
3. Radical mastoidectomy
 Depending on the fact whether postero-superior canal is removed or not,
1. Canal Wall Up mastoidectomy
2. Canal Wall Down mastoidectomy.

36.  Indications:-
Unsafe chronic supperative otitis media with extensive cholesteatoma.
Chronic suppurative otitis media with complications.
For labyrinthectomy in suppurative labyrinthitis.
Glomus tumor invading mastoid bone.
Malignant disease of the middle ear.

37. Operation:
 Incision:- Post-auricular is made about ¼ behind the post-auricular groove.
 The incision should extend from above the level of the auricle to near mastoid tip.
 The temporalis muscle above is elevated along with periosteum.
 After the cortical cavity is made, aditus & attic are completely expose by drilling
out the wall, but extreme care must be taken to the facial nerve which lies on the
medial wall of the aditus.
 Cholesteatoma & other diseased tissues are thoroughly removed.
 The posterior meatal wall (bony facial bridge) between the external canal &
antrum, is progressively removed.
 The stapes is retained.
 The whole cavity is carefully inspected so as not to leave any pockets of squamos
epithelium
 The wound is closed by interrupted sutures.

38.  MOLLISONS’S MASTOID RETRACTOR

39.  JANSEN’S SELF RETAINING MASTOID
 LEMPERT’S ENDAURAL SPECULUM

43.  Instruments

47. Complications
 Trauma to Facial Nerve-FACIAL PARALYSIS
 Dislocation of incus
 Horizontal Semicircular injury with POSTOP GIDDINESS & NYSTAGMUS
 Trauma to Dura of middle cranial fossa
 Sigmoid Sinus and Jugular Bulb Injury- PROFUSE BLEEDING.
 POSTOP WOUND INFECTION

48.  Removal of footplate of stapes and insertion of graft or prosthesis
 Indications:
 In profound cochlear hearing loss with stapes fixation prior to prescribing
hearing aid ( provided Speech discrimination is good)

49. Surgical steps

50. Incision and TM flap elevation

51.  Identifying and separating chorda tympani

52.  Curretage of canal wall
 Measurement of prosthesis

53.  Separating the IS joint
 Fenetsra created in footplate

54.  Removal of stapes superstructure
 Excising the footplate

55.  Polythene strut interposition

56. Complications
During TM flap elevation
Ear drum perforation (2-5%)
Facial nerve palsy (0.02 – 0.5%)
Chorda tympani lesions
Incus luxation (Anterior/posterior/lateral)
During removal of stapes
Sensorineural hearing loss (3.5 – 4%)
Floating footplate
After stapedectomy
Perilymph fistula (0.9% - 2.6%)
Delayed SNHL
 Delayed facial nerve palsy
 Cholesteatoma Labyrinthitis / Meningitis

57.  Implantation of electronic devices that bypass chochlea and stimulates auditory
nerves
 Not a hearing aid
 A true bionic sense organ
 Mechanism of action
Bypasses all hearing mechanism till hair cells and directly stimulate the auditory
nerve

58.  Consist of
 Internal component:- Electrode array and receiver-stimulator
 External component: Speech processor, head piece and battery

60. Indications
Adults
 Age – More than 18 years
 Bilateral severe to profound Sensorineural hearing loss.
 Post-lingual Deafness
 Little or no benefit from hearing aids.
 Sentence recognition test <50%
 No anatomical contraindication
 Lack of medical contraindication including psychological instability
Children
 12 months or older
 Bilateral severe-to-profound sensorineural hearing loss with PTA of 90 dB or
 greater in better ear
 No appreciable benefit with hearing aids (parent survey when <5 y or 30% or less on sentence
recognition when >5 y)
 Tolerance for wearing hearing aids
 Enrolled in aural/oral education program
 No medical or anatomic contraindications
 Motivated parents

61. Contraindications
 Vestibulocochlear nerve lesion
 CN VIII atresia
 Agenesis of cochlea (michel deformity)
 Neurofibromatosis II
 Active middle ear disease
 Psychosis, mental retardation, severe organic brain dysfunction
 Unrealistic expectations

62. Selection of Ear
Most radiographically favorable anatomy (well-pneumatized mastoid, normal
facial nerve anatomy, normal inner ear development, and patent cochlea)
Least obstructed labyrinth

63. Surgical technique
Approaches:
Trans-mastoid approach
Middle cranial fossa approach
 Pre-op antibiotic
• Under GA
• Without muscle relaxant
• Facial nerve monitor

64.  Infiltration with local anesthesia
 Post-auricular Incision with posterosuperior extension (from temporalis muscle
superiorly to mastoid periosteum inferiorly)

65.  Skin flaps are then developed anteriorly to the ear canal and posteriorly to allow
for placement of the internal receiver.
 An anteroinferiorly based musculoperiosteal flap is then created by incising the
temporalis fascia, muscle, and periosteum

66.  Mastoidectomy is done
 Once mastoid antrum is entered LSSC identified and drilling continuous
anterosuperiorly until the body of the incus is identified
 Posterior tympanotomy through facial recess

67.  Bony recess for internal receiver is drilled (templates and dummy receiver)
 Cochleostomy done (1mm diamond burr)
 Device is placed in this recess and secured in place
 Electrode is inserted into the scala tympani through cochleostomy and sealed with
temporalis muscle

68.  Intraoperative measurements (neural-response telemetry and impedence testing)
are obtained to confirm proper functioning of the device before or during wound
closure.
 Wound is closed in layers

69. Complications
 Facial nerve injury
 Alteration of taste
 Infection
 Dizziness
 Wound dehiscence
 Device failure
 CSF leak
 Meningitis
 Otitis media
 Device extrusion
 Displacement of electrodes

70. Post op care
 Can be discharge on the day of operation
 7 days oral antibiotic
 Mastoid dressing opened after 24 hours
 Follow up visit 1 week
 External device fitted 4 weeks after the surgery
 programming and rehabilitation begin

71. PREOPERATIVE CARE
Assess the client’s hearing or verify documentation of preoperative hearing
assessment. These data are important in evaluating the results of the surgical
procedure.
Agree on a means of communication to be used after surgery.
Hearing may be impaired after surgery.
Explain that blowing of the nose, coughing, and sneezing are restricted to prevent
pressure changes in the middle ear and potential disruption of the surgical site.
If the client needs to cough or sneeze, leaving the mouth open minimizes pressure
changes in the middle ear.

72. POSTOPERATIVE CARE
 Assess for bleeding or drainage from the affected ear.
 Infection and hemorrhage are possible complications.
 Administer antiemetics as ordered to prevent vomiting.
 Vomiting may increase the pressure in the middle ear, disrupting the surgical site.
 Elevate the head of bed and have the client lie on the unaffected side. This position
minimizes the pressure in the middle ear.
 Assess for vertigo or dizziness, especially with ambulation or movement in bed. Avoid
unnecessary movements such as turning.Take measures to ensure safety when the client
gets up and ambulates. Surgery on the ear may disrupt the client’s equiibrium,
increasing the risk of falling.
 Assess the client’s hearing postoperatively. Stand on the client’s unaffected side to
communicate and use other measures such as written messages as needed for effective
communication with the hearing-impaired client.
 Reassure the client that decreased hearing acuity immediately after surgery is expected.
Hearing improvement, if an expected result of the ear surgery, typically does not occur
until ear plugs are re moved, and edema and drainage at the operative site have
resolved.
 If no reconstruction of the middle ear is done or the cochlea is involved, permanent
hearing loss in the affected ear may be an expected result.
 Remind client to avoid coughing, sneezing, or blowing the nose. These increase
pressure in the middle ear.

73. Provide instructions for home care.
 To prevent contamination of the earcanal, avoid showers, shampooing, and
immersing the head until the physician says you can do so.
 Keep the outer ear plug clean and dry, changing it as needed. Do not remove inner
ear dressing until the physician so orders.
 Avoid blowing the nose; if you need to cough or sneeze, keep the mouth open.
 Do not swim or dive without physician approval.
 Check with the physician regarding air travel.
 Meclizine hydrochloride (Antivert) or other antiemetic/ antihistamine medication
may be necessary for up to 1 month following surgery.
 Fever, bleeding, increased drainage, increased dizziness, or decreased hearing
after discharge may indicate a complication.
 Notify the physician if any of these occur.