This document provides information about mastoidectomy surgery. It begins with an introduction stating the primary aim of ear surgery is to remove disease and make the ear safe and dry, while preserving hearing if possible. It then discusses the classification of mastoidectomies as cortical, modified radical, or radical, depending on whether the posterior canal wall is removed or retained. The rest of the document details the surgical anatomy, instruments, pre-operative imaging, and techniques for performing a cortical mastoidectomy, which is defined as the complete removal of accessible mastoid air cells while keeping the posterior canal wall intact.
This is a motivational and scientific presentation related to Tympanomastoid Surgeries in Otorhinolaryngology. This presentation is prepared to motivate junior colleagues to take up Otology (Medical Science related to Ear disease), learn and excel in the same for the benefit of the humanity suffering from Ear diseases. This presentation mainly addresses the basic concepts in commonly performed Micro-Ear surgeries like Myringoplasty, Tympanoplasty, Cortical mastoidectomy and Canaloplasty. The author has used management principles like Total Quality Management, Six Sigma and SWOT analysis to improve quality of the care provided to patients.
Myringotomy (from Latin myringa "eardrum") is a surgical procedure in which a tiny incision is created in the eardrum to relieve pressure caused by excessive buildup of fluid, or to drain pus from the middle ear. A tympanostomy tube is inserted into the eardrum to keep the middle ear aerated for a prolonged time and to prevent reaccumulation of fluid. Without the insertion of a tube, the incision usually heals spontaneously in two to three weeks. Depending on the type, the tube is either naturally extruded in 6 to 12 months or removed during a minor procedure.
This is the presentation by Dr. Padmal De Silva - Head of the Research Unit, National Institute of Health Sciences, Sri Lanka done on the inauguration of Medical Research Consortium. http://learnent.net/research-symposium-dgh-hambantota/
Spaces of middle ear and their surgical importanceDr Soumya Singh
one of the imp topics in ENT that should be understood very thoroughly if u want to pursue as an otologist.I tried to simplify the topic with simple diagrams and models for better understanding .
a basic description of temporal bone anatomy which is necessary for primary radiologic evaluation of temporal bone imaging and some important points and differential diagnoses in related imaging.
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Chronic Otitis Media - Squamosal type ( UG)AlkaKapil
Chronic Otitis Media - Squamosal / atticoantral/ unsafe Type
Theories of cholesteatoma
cholesteatoma
levenson's criteria
congenital cholesteatoma
classification of cholesteatoma
sade's classification of retraction of pars tensa
Toss classification of pars flaccida retraction
cholesterol granuloma
clinical features of Squamosal CSOM
Complications of COM/CSOM
Investigations - HRCT Temporal bone
Mastoid exploration
cortical mastoidectomy
modified radical mastoidectomy
Radical mastoidectomy
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
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The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
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Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
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These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
3. INTRODUCTION
PRIMARY AIM OF ANY EAR SURGERY IS TO
REMOVE THE DISEASE,AND MAKE THE
EAR SAFE AND DRY, AND SECOND
PRIORITY is to PRESERVE/RECONSTRUCT
HEARING, BUT NEVER AT THE COST OF
PRIMARY AIM…..
Mastoidectomy provides an access to remove
1.diseased air cell of mastoid in mastoiditis
2.cholesteatoma
3.granulation tissue in otitis media
4. EXPLORATORY MASTOIDECTOMY-
The initial MASTOID EXPLORATION till
antrum is reached is same for all mastoid
surgeries.
Preservation of the canal wall is preferred.
The decision to remove the wall is most
often made during surgery, when the
extent of the disease is fully
appreciated.
Mastoidectomy(cwu) is also used as a
standard approach for
1. Cochlear implantation,
2. Excision of tumors of lateral skull base(like
schwannomas, meningiomas, glomus-temp
5. CLASSIFICATIONS
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.
7. CWU PROCEDURES
DISEASE REMOVED WHILE RETAINING THE
POSTERIOR WALL INTACT.
THUS, AVOIDING AN OPEN MASTOID
CAVITY
ADV-DRY EAR WHICH PERMITS EASY
RECONSTRUCTION OF HEARING
DISADV-RESIDUAL/RECURRENCE OF
CHOLESTEOTOMA in these cases is very high
SO, RE-EXPLORATORY FOLLOW-UP IS
ADVICED AFTER 6 MONTHS
8. 1)Disease is removed both permeatally and
through-
2)POSTERIOR TYMPANOTOMY
APPROACH-
A window is created b/w mastoid and middle ear,
through facial recess, to reach sinus tympani, don
along with cortical mastoidectomy
COMBINED
APPROACH-
9.
10. Comparison of CWU vs
CWD
MEATUS
DEPENDENCE
RECURRENCE/RE
SIDUAL DISEASE
2ND
LOOK
SURGERY
PATIENT
LIMITATIONS
AUDITORY
REHABILLITATIO
N
CWU
NORMAL
DOES NOT
REQUIRE ROUTINE
CLEANING
HIGH RATE
AFTER 6
MONTHS TO RULE
OUT
CHOLESTEOTOMA
NONE, ALLOWED
SWIMMING
EASY TO WEAR
AID IF NEEDED
CWD
WIDELY OPEN MEATUS
COMMUNICATING WITH
MASTOID
HIGH DEPENDENCE ON
DOCTOR FOR YEARLY
CLEANING OF MASTOID
CAVITY
LOW RATE, THUS A
SAFER PROCEDURE
NOT REQUIRED
SWIMMING CAN LEAD TO
INFECTION
PROBLEMS IN FITTING A
HEARING AID DUE TO
LARGE MEATUS AND
SOMETIMES, DUE TO
INFECTED MASTOID
CAVITY
11. POST-SURGICAL
PROBLEMS- {5 D’S}
(MAINLY IN CWD)
1.Deafness-30dB
2.Dizziness-on thermal stimulation of
LSC(due to a single cavity)
3.Debris Collection- desqamated
epithelium
4.Discharge from infected debris
5.Dependence-on doctor for yearly
cleaning of cavity
12. The temporal bone consists of four parts:
squamous, tympanic, mastoid, and petrous
temporal line extends posteriorly from the
zygomatic root and is the insertion site for the
temporalis muscle.
SURGICAL
ANATOMY
13.
14.
15. A cribriform area lies within Macewen’s triangle,
an imaginary triangle defined by three lines-
1. Temporal line
2. Line formed by the superior and posterior margins
of the external bony meatus (This line goes through
the suprameatal spine)
3. Line drawn perpendiular to the first line and
tangential to the second.
Mastoid antrum lies around 1.25 to 1.5 cm deep
from the surface of Macewen’s triangle.
Cymba concha is the soft tissue anatomical
landmark for the mastoid antrum.
16.
17. Fascial recess is a
depression in posterior
wall,Bounded medically by
vertical part of VII and
laterally by
Chorda tympani.
Exposure of fascial recess
provides a direct approach
Into the middle ear without
disturbing the posterior
canal.
This procedure is called
posterior tymaponotomy,
used in
Intact canal technique
18. Mastoid develops from the sqamous and petrous bones
Petrosquamosal suture may persist as a bony plate called KORNER’S
SEPTUM
Imp. Surgically as it may cause difficulty in locating antrum and other
deeper air cells
Leading to incomplte removal of disease
Thus, MASTOID ANTRUM CANNOT BE REACHED UNLESS IT IS
REMOVED
26. ADEQUATE-CONTINUOUS-IRRIGATION
while drilling-
1.to wash away bone dust-improving visualisation
2.to decrease risk of heat injury from drilling
3.to maintain a clean cutting surface on the bur.
Haemostasis for bleeding-
1.bipolar cautery
2.bone wax
3.diamond spurr(lot of bone dust seals bleeding
vessels)
27. a) cutting bur b)cutting diamond bur (note the
course texture) c) a diamond bur.
28. Cutting burrs are efficient at removing large
amounts of bone in a small amount of time.
Diamond burrs are very good at delicate
dissection around important structures, thinning
the bone off the sigmoid sinus, tegmen, facial
nerve, and opening the facial recess.
During the mastoidectomy, larger burrs are used
first and the burr size is sequentially decreased
as the areas of dissection get narrower.
29. PRE-OPERATIVE IMAGING
A pre-op TEMPORAL BONE HRCT is used to
determine-
1)Location of tegmen,sigmoid sinus, facial
nerve,inner ear structure or a low lying dura
2)to determine any abnormal anatomy of
temporal bone due to disease or previous
surgery
3)identification of dehiscences in
tegmen/sinus- may have risk of CSF leak,
encepalocele, bleeding or rarely,air embolus
4)Fistulas into otic capsule
30. CORTICAL
MASTOIDECTOMY
CORTICAL/SIMPLE/COMPLETE
MASTOIDECTOMY (Schwartze 1873) is
COMPLETE EXENTERATION OF ALL
ACCESSIBLE MASTOID AIR CELLS and
converting them into a single cavity.
It is a CWU procedure where posterior meatal
wall is left intact.
MIDDLE EAR STRUCTURES ARE NOT
DISTURBED IN THIS PROCEDURE.
31. INDICATIONS OF CORTICAL MASTOIDECTOMY
1) ACUTE Coalescent Mastoiditis
2) Masked Mastoiditis (latent)
3) INCOMPLETELY RESOLVED AOM with reservoir
sign
4) CSOM TTD Active Refractory to antibiotics.
5) Secretory otitis media Refractory to antibiotics
6) Diffuse serous and diffuse suppurative labrynthitis (of acute
mastoiditis)
7) Approach to:
-Endolymphatic sac surgery.
-Facial nerve decompression.
-Vestibulo cochlear nerve section.
-Trans/Retrolabyrinthine Approach for CP angle access
in ACOUSTIC NEUROMA(and other tumors)
-Cochlear implant surgery.
32. Specific indications of cortical
matoidectomy in acute mastoiditis-
1) Subperiosteal abscess
2) Sagging of posterio-superior meatal wall
3) Positive reservoir sign
4) Worsening of patient even after adequate
medical treatment for 24hrs
5) Complicated mastoiditis- facial
paralysis,labrynthitis,i/c complication
DRY EAR FOR 6 WEEKS IS THE
MOST IMPORTANT PRE
OPERATIVE PRE REQUISITE
33. OPERATIVE
TECHNIQUES(CWU)
Position-
supine with face turned to one side and ear to be
operated is placed at the uppermost position
Preparation-
General anesthesia without paralytic agents and with
continuous facial nerve Monitoring.
Tragus and postauricular skin are injected with 1%
lidocaine with epinephrine (1: 100,000) to provide
hemostasis and local anesthesia.
“Pre-scrub" the ear and the entire side of the head,
including hair, with betadine.
35. 1)ENDAURAL APPROACH-
A)excision of osteomas of ear canal
B)large tympanic membrane perforation
C)attic cholesteotomas with limited extension into antrum
D) MRM where disease limited to attic,antrum or part of
mastoid
LEMPERT I-
Semicircular incision from 12o to 6o clock position in
posterior meatal wall at bony-cartilagenous junction
LEMPERT II-
Start from first incision at 12o clock and then passes
upward curvillinear b/w tragus and crus of helix.
It passes through the incisura termanalis and thus does
not cut the cartilage.
Used for both mastoid and
external canal surgeries
SURGICAL APPROACHES TO THE EAR in
CWU
36. 2)POSTAURAL/WILDE’S INCISION-
A)starts from highest attachment of pinna, follows the
curve 1cm behind retroauricular groove and ends at
mastoid tip.
B)Some surgeons prefer it in sulcus itself
C)Slanting posteriorly in <2yrs children due to
underdeveloped mastoid with a superficial facial nerve
Used in-
1)cortical mastoidectomy
2)MRM/RM
3)tympanoplasty-when perforation extends anterior to
handle of malleus
37. SURGICAL APPROACH
& INCISIONS 1)INCISION-
The postaural incision is made from
helical rim to mastoid tip,
approximately 1 cm posterior to the
sulcus.
Incision cuts soft tissues upto
periosteum, but
temporalis muscle is spared
38.
39. 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 mastoid
surface
Sternoclidomastoid fibres are sharply cut
Self retaining mastoid retractor is applied
40. 3)Removal of mastoid cortex and
exposure of antrum
Cortex removed with burr
Antrum is exposed in area of
suprameatal/McEwens triangle
12-15mm deep to surface
41. • ADEQUATE-CONTINUOUS-
IRRIGATION while drilling-
• 1.to wash away bone dust-improving
visualisation
• 2.to decrease risk of heat injury from drilling
• 3.to maintain a clean cutting surface on the
bur.
• Haemostasis for bleeding-
• 1.bipolar cautery
• 2.bone wax
• 3.diamond spurr(lot of bone dust seals
bleeding vessels)
42. 4)Removal of mastoid air
cells
All accessible mastoid air cells are
removed leaving behind the bony
plate of tegmen tympani above, the
sinus plate behind and posterior
meatal wall infront.
43. The surgeon should look for the emergence of
a pink hue under the bone as it is thinned
over the tegmen, accompanied by a change
(more "tinny") in the sound of the burr.
Once located, the surface of the tegmen is
followed medially toward the antrum.
The middle fossa dura is always delineated as
it is the superior extent of the dissection.
44. After identification of the tegmen, cortical bone
is removed behind the EAC, keeping the
posterior wall of the EAC thin, but intact.
A key landmark in performing mastoid surgery
is the antrum with the dome of the horizontal
semicircular canal (HSCC) along its floor as a
bulge. The ease of locating the antrum
depends largely on the degree of mastoid
pneumatization.
45. As the bone over the sigmoid sinus is thinned,
a bluish hue will become apparent beneath
the bone.
With the tegmen, sigmoid sinus, and posterior
canal wall identified, the antrum can now be
dissected, following the tegmen anteriorly.
Korner's septum, the embryologic remnant of
the fusion plane between the petrous and the
squamous bones is often encountered next.
After penetrating Koerner's septum, the antrum
is uncovered and the surgeon can identify the
lateral semicircular canal.
46.
47. The mastoid segment of the facial nerve also
lies medial to the plane of the short process of
the incus at the base of the posterior canal wall.
This is why it nerve can get injured.
If the canal wall is not thinned appropriately, a
wall of air cells continues to cover the facial
nerve, and the dissection is carried too far
posteriorly, potentially exposing the posterior
side of the facial nerve to injury.
Removing air cells from the posterior bony
canal wall until it is only a few millimeters thick
is essential.
48. 5)Removal of mastoid tip
and finishing the cavity
Lateral wall of MASTOID TIP is removed,
exposing fibres of posterior belly of
digastric
ZYGOMATIC CELLS(in zygoma root) and
RETROSINUS CELLS(b/w sinus plate and
cortex) are removed
A finished cavity should have BEVELLED
EDGES so that soft tissue can easily sit
and obliterate the cavity.
49. 6)CLOSURE
the ear canal and mastoid cavity are irrigated
extensively with antibiotic-containing saline solution to
remove any bone dust and remaining squamous
debris.
The self-retaining retractors are removed
The postauricular incision is closed in two layers.
In case of infection or bleeding, a drain maybe left at
lower end of incision for 24-48hrs
Meatal pack is kept to avoid stenosis of ear canal
Mastoid dressing is applied
50. The incision is covered in antibiotic ointment
and a Glasscock ear dressing (Otomed) is
applied.
51. POST-OPERATIVE CARE
1)antibiotics started preoperatively are
continued postop for at least 1 week.
If culture swab is taken during surgery, the
sensitivity may dictate a change in drug.
2)drain, if put, is removed in 24-48 hrs and
sterile dressing is done.
3)stitches are removed on the 6th
day.
52. 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