Middle Ear and Mastoid Microsurgery, 2nd Edition

Middle Ear and Mastoid Microsurgery, 2nd EditionAuthor(s): Hiroshi Sunose, Alessandra Russo, Abdelkader Taibah, Fernando Mancini, Mario Sanna

Based on more than 30 years’ experience and over 20,000 clinical cases, the second edition of Middle Ear and Mastoid Microsurgery presents detailed, step-by-step procedures for the full spectrum of otologic disorders,from assessment and preoperative considerations to descriptions of both common and complex surgeries.

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The superb intraoperative images and schematic drawings, combined with instructional text, facilitate an in-depth understanding of surgical anatomy and operative steps that is unparalleled in the literature.

New to the second edition of this landmark text:

  • Nearly 1,800 vivid, full-color intraoperative images that take readers through every operative sequence and offer a unified management approach to all procedures
  • Expanded chapter on temporal bone anatomy and dissection with CT scans correlated to dissection images of normal temporal bone, which is crucial for a full understanding of surgical anatomy and 3-D relationships between important structures
  • Updated chapter on paragangliomas, offering proven surgical solutions to this difficult pathology
  • Revised section on hemipetrosectomy, with treatments for intractable otorrhea in dead ears and other severe pathologies widely infiltrating the middle ear
  • Overview of new approaches to glomus tumor surgery
  • Coverage of the remarkable advances in cochlear implant technology for profound sensorineural hearing loss

Complete with general operating room principles, anesthesia, and technical considerations, plus guidance, pitfalls, problems and potential complications, this comprehensive book is an in-depth review of modern middle ear surgery. From temporal bone anatomy to canalplasty to stapes surgery, it sets the standard as the authoritative, one-stop reference for all otologic surgeons, residents, and medical students.

Contents
1 Anatomy and Radiology of the Temporal Bone ….. 1
The External Auditory Canal…………………….. 1
The Tympanic Membrane ………………………. 1
The Ossicular Chain……………………………. 1
The Tympanic Cavity…………………………… 2
The Medial Wall ………………………………. 2
The Posterior Wall……………………………… 2
The Attic …………………………………….. 2
The Antrum………………………………….. 3
The Labyrinth ………………………………… 3
The Jugular Bulb………………………………. 3
The Carotid Artery…………………………….. 3
The Facial Nerve………………………………. 3
Surgical Anatomy of the Canal Wall Down (Open)
Tympanoplasty……………………………….. 13
Surgical Anatomy of the Canal Wall Up (Closed)
Tympanoplasty……………………………….. 15
Computed Tomography of the
Temporal Bone and Related Anatomy …………….. 19
Axial Sections ………………………………… 20
Coronal Sections ………………………………. 30
2 Operating Room Setup . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Arrangement of the Room ……………………… 34
Position of the Patient …………………………. 35
Special Considerations in Stapes Surgery ……………. 35
Preparation of the Operative Site ………………… 36
Position of the Surgeon ………………………… 36
Position of the Surgeon’s Hands …………………. 36
Suction and Irrigation………………………….. 38
Monopolar and Bipolar Coagulation ……………… 38
Microscope ………………………………….. 38
Facial Nerve Monitoring ……………………….. 38
Instruments………………………………….. 38
Hints and Pitfalls for Operating Room Setup …………. 47
3 Anesthesia ……………………………….. 48
Local Anesthesia ……………………………… 48
General Anesthesia ……………………………. 48
Hints and Pitfalls for Anesthesia…………………… 51
4 General Technical Considerations …………….. 52
Rules and Hints……………………………….. 52
Drilling ……………………………………… 52
Suction and Irrigation ………………………….. 53
Hemostasis…………………………………… 54
Dissection……………………………………. 54
5 Decision Making in Middle Ear Surgery ………… 55
How Should We Choose Our Patients? ……………. 55
Canalplasty…………………………………… 55
Myringoplasty ………………………………… 55
Ossiculoplasty ………………………………… 55
Tympanoplasty ……………………………….. 55
Stapes Surgery………………………………… 55
Strategy in the Only Hearing Ear…………………. 55
Tympanostomy Tube……………………………. 55
Noncholesteatomatous Chronic Otitis Media…………. 55
Cholesteatoma ………………………………… 55
Ossiculoplasty ………………………………… 56
Neoplasm ……………………………………. 56
Stapes Surgery………………………………… 56
Staging Strategy ……………………………… 56
Noncholesteatomatous Chronic Otitis Media…………. 56
Cholesteatoma ………………………………… 56
Stapes Surgery………………………………… 56
Strategy for Revision Surgery……………………. 57
Canal Stenosis ………………………………… 57
Myringoplasty ………………………………… 57
Ossiculoplasty ………………………………… 57
Tympanoplasty in Cholesteatoma …………………. 57
Stapes Surgery………………………………… 57
6 Ventilation Tube Insertion …………………… 58
Indications …………………………………… 58
Contraindications ……………………………… 58
7 General Otosurgical Procedures………………. 61
Retroauricular Skin Incision …………………….. 61
Surgical Steps …………………………………… 61
Harvesting Grafting Material ……………………. 63
Temporalis Fascia (Retroauricular Scar Tissue) ……….. 63
Surgical Steps …………………………………… 63
Tragal Cartilage and Perichondrium ……………….. 65
Split-thickness Skin Graft ……………………….. 69
Incision of the External Auditory Canal ……………. 70
Surgical Steps …………………………………… 70
Case 7.1–7.3 ……………………………………. 73
Canalplasty (Calibration of the Bony Canal Walls) …… 78
Surgical Steps …………………………………… 78
Case 7.4–7.5 ……………………………………. 81
Skin Closure …………………………………. 90
8 Preoperative and Postoperative Care ………….. 91
Preoperative Care …………………………….. 91
Postoperative Care ……………………………. 91
Dressing …………………………………….. 91
Postoperative Management………………………. 91
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VIII Contents
9 External Auditory Canal …………………….. 92
Exostosis and Osteoma ………………………… 92
Surgical Steps …………………………………… 92
Case 9.1–9.2 ……………………………………. 96
Hints and Pitfalls for Exostosis ……………………. 107
Hints for Beginners …………………………….. 107
Stenosis of the External Auditory Canal …………… 107
Postinflammatory and Postoperative Stenoses ……….. 107
Surgical Steps …………………………………… 109
Case 9.3–9.4 ……………………………………. 110
Hints and Pitfalls for Canal Stenosis ……………….. 118
Cholesteatoma of the External Auditory Canal ……… 118
Case 9.5 ……………………………………….. 119
10 Myringoplasty ……………………………. 122
Indications …………………………………… 123
Contraindications ……………………………… 123
Retroauricular Myringoplasty …………………… 124
Surgical Steps …………………………………… 124
Case 10.1–10.6 ………………………………….. 135
Transcanal Myringoplasty ………………………. 171
Surgical Steps …………………………………… 171
Case 10.7 ………………………………………. 172
Problems and Solutions in Myringoplasty …………. 175
Pathological Status of the Anterior Part of the
Tympanomeatal Flap …………………………… 175
Thickened Tympanomeatal Flap…………………… 175
Everted Mucosa ……………………………….. 175
Atelectasis …………………………………… 176
Epithelialization in the Medial Aspect of the Tympanic
Membrane …………………………………… 176
Limited Epithelialization in the Middle Ear ………….. 176
Extensive Epithelialization in the Middle Ear ………… 176
Tympanosclerosis ……………………………… 177
Extensive Defects of the Middle Ear Mucosa …………. 177
Revision Myringoplasty ………………………… 178
Case 10.8 ………………………………………. 181
Hints and Pitfalls for Myringoplasty ……………….. 185
11 Ossiculoplasty ……………………………. 187
Indications …………………………………… 187
Contraindications ……………………………… 187
Approaches…………………………………… 187
Considerations Regarding Atelectasis and Adhesive
Otitis Media………………………………….. 188
Case 11.1 ………………………………………. 189
Considerations Regarding Tympanosclerosis……….. 190
Tympanosclerosis with Intact Tympanic Membrane …… 191
Tympanosclerosis with Tympanic Membrane Perforation. . 191
Management of the Stapes in Tympanosclerosis………. 191
Surgical Steps …………………………………… 191
Ossiculoplasty in Various Situations ……………….. 197
Closure ……………………………………… 204
Case 11.2–11.11…………………………………. 204
Hints and Pitfalls for Ossiculoplasty ……………….. 238
Revision Ossiculoplasty ………………………… 239
Case 11.12 ……………………………………… 242
12 Simple Mastoidectomy …………………….. 245
Indications …………………………………… 245
Landmarks …………………………………… 245
Surgical Steps …………………………………… 245
13 Canal Wall Up (Closed) Tympanoplasty ……….. 248
Indications …………………………………… 248
Canal Wall Up (Closed) Tympanoplasty . . . . . . . . . . . . . . 249
Surgical Steps …………………………………… 249
Case 13.1–13.6 ………………………………….. 256
Second-Stage and Revision Surgery after Canal Wall Up
Technique …………………………………… 301
Surgical Steps …………………………………… 302
Case 13.7–13.10…………………………………. 304
Hints and Pitfalls ………………………………. 324
14 Canal Wall Down (Open) Tympanoplasty ……… 326
Indications …………………………………… 326
Canal Wall Down (Open) Tympanoplasty ………….. 326
Surgical Steps …………………………………… 326
Meatoplasty …………………………………. 331
Surgical Steps …………………………………… 331
Packing and Closure …………………………… 333
Case 14.1–14.3 ………………………………….. 333
Hints and Pitfalls ………………………………. 353
Modified Bondy Technique ……………………… 354
Indications …………………………………… 354
Surgical Steps …………………………………… 354
Case 14.4–14.8 ………………………………….. 356
Hints and Pitfalls of the Modified Bondy Technique……. 378
Radical Mastoidectomy ………………………… 378
Indications …………………………………… 378
Surgical Steps …………………………………… 378
Second Stage Surgery in Open Technique …………. 379
Revision Surgery after Open Technique …………… 379
Surgical Steps …………………………………… 379
Case 14.9 ………………………………………. 381
Hints and Pitfalls of Revision Surgery ………………. 385
15 Special Considerations Regarding Paraganglioma
(Classes A and B) ……………………………… 386
Surgical Strategy ………………………………… 389
Surgical Steps …………………………………… 389
Case 15.1–15.8 ………………………………….. 397
Hints and Pitfalls of Paraganglioma Surgery …………. 448
16 Problems and Solutions in Mastoid Surgery……. 449
Labyrinthine Fistula …………………………… 449
Bone Erosion in the Tegmen…………………….. 452
Facial Nerve Paralysis ………………………….. 452
New Bone Formation ………………………….. 454
Meningoencephalic and Dural Herniation …………. 454
Case 16.1–16.2 ………………………………….. 455
17 Stapes Surgery …………………………… 460
Indications …………………………………… 460
Contraindications ……………………………… 460
Approach ……………………………………. 460
Anesthesia …………………………………… 460
Surgical Steps …………………………………… 461
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Contents IX
Case 17.1–17.4 ………………………………….. 473
Problems and Solutions ………………………… 497
Disease States…………………………………. 497
Anatomical Variations ………………………….. 500
Surgical Trauma……………………………….. 504
Case 17.5–17.7 ………………………………….. 506
Hints and Pitfalls for Stapes Surgery ……………….. 510
Revision Stapes Surgery………………………… 511
Ossicular Chain Problems ……………………….. 512
Prosthetic Failure ……………………………… 513
Medial Problems after Stapedectomy . . . . . . . . . . . . . . . . . . . 514
Case 17.8–17.15…………………………………. 517
Hints and Pitfalls for Revision Stapes Surgery ………… 533
18 Obliteration of the Middle Ear
(Subtotal Petrosectomy)……………………….. 534
Indications …………………………………… 534
Case18.1–18.4 ………………………………….. 535
19 Cochlear Implantation …………………….. 549
Indications for cochlear implantation ………………. 549
Indications for Cochlear Implantation with Subtotal
Petrosectomy and Obliteration of the Middle Ear ……… 549
Case 19.1–19.10 ………………………………… 550
Hints and Pitfalls for Cochlear Implantation …………. 584
20 Management of Iatrogenic Injuries…………… 585
Bleeding from the Dura ………………………… 585
Bleeding from the Sigmoid and Other Sinuses ……… 585
Bleeding from the Jugular Bulb ………………….. 585
CSF Leakage …………………………………. 585
Labyrinthine Fistula …………………………… 586
Disarticulation of the Incus……………………… 586
Fracture of the Stapes …………………………. 586
Tear in the Tympanic Membrane…………………. 586
Tear in the Meatal Skin…………………………. 586
Facial Nerve Injury…………………………….. 586
Case 20.1 ………………………………………. 588
Further Reading………………………………. 591
Subject Index ………………………………… 593

1 Anatomy and Radiology of the Temporal Bone

The basic anatomical knowledge of important structures that
may be encountered during middle ear surgery is described here.
Because the three-dimensional anatomy of the middle ear is so
complicated, it is impossible to appreciate it in its entirety only
through these flat pictures. Intensive work in the temporal bone
dissection laboratory is mandatory.
▀ The External Auditory Canal
The osseous portion accounts for the medial one-third of the
external auditory canal. The skin lying on the bony canal is extremely thin, only 0.2mm in thickness, and requires meticulous
care during dissection. Two sutures between elemental structures forming the temporal bone appear in the canal. The tympanosquamous suture is located anterosuperiorly and the tympanomastoid suture posteroinferiorly. Connective tissue enters into
these suture lines and sharp dissection may be required during
meatal skin elevation. The glenoid fossa, which receives the mandibular condyle to form the temporomandibular joint, is located
just anterior to the canal and is separated from the canal only by
a thin bony shell.
▀ The Tympanic Membrane
The conically shaped tympanic membrane is tilted anteroinferiorly. Because of this, the anteroinferior bony wall is longer than
the posterosuperior one, and the anterior tympanomeatal angle
is more acute than the posterior. The view of the anterior angle is
often hindered by a bony protrusion of the anterior wall. Adequate
visualization of this angle is the key for successful tympanic
membrane reconstruction. The tympanic membrane is composed of three layers. It is covered laterally with an epidermal
layer, and medially with a mucosal layer. Between these two
layers there is a fibrous layer, the lamina propria. The lamina propria may be lost in an atrophic tympanic membrane, and may be
thickened by a tympanosclerotic plaque. The tympanic membrane is divided into two parts. The pars tensa, located inferiorly
to the lateral process of the malleus and the anterior and posterior malleal folds, occupies the majority of the tympanic membrane. The lamina propria thickens in the periphery of the pars
tensa to form the tympanic annulus. The tympanic annulus is
attached to a groove on the bony canal called the tympanic sulcus. The pars flaccida is located superiorly to the lateral process
of the malleus, and delineated superiorly by a bony notch in the
superior canal wall called the Rivinus notch. Medial to the pars
flaccida and lateral to the neck of the malleus is the Prussak
space, where epitympanic cholesteatoma starts to invaginate medially from the pars flaccida.
▀ The Ossicular Chain
The Malleus
The manubrium of the malleus is firmly attached to the tympanic membrane. Its tip corresponds to the umbo of the tympanic
membrane, which is the bottom of its conical shape. The lateral
process is located at the superolateral end of the manubrium.
Due to its proximity to the superolataral canal wall, meticulous
care should be taken not to touch this process with burrs during
canalplasty. The head of the malleus is located in the attic, and its
neck connects the head and the manubrium. The tendon of the
tensor tympani muscle attaches to the medial surface of the neck.
Contraction of the muscle pulls the ossicle medially, and the resultant tension to the tympanic membrane limits sound transmission to the inner ear to some extent. The head of the malleus
is supported by the superior suspensory ligament and the anterior suspensory ligament.
The Incus
The body of the incus forms an articulation anteriorly with the
head of the malleus. The short process of the incus projects posteriorly. The short process is lodged in the fossa incudis located
just anterior to the eminence of the lateral semicircular canal.
The long process projects into the tympanic cavity and forms an
articulation with the stapes at its lenticular process. The incus is
supported by the malleus anteriorly, and the posterior incudal
ligament posteriorly.
The Stapes
The smallest bone in the human body is located in the oval window. The stapes sits in a deep depression called the oval window
niche as described below. The head of the stapes forms an articulation with the incus. The stapedius muscle inserts onto the head
and the posterior crus. The footplate is accommodated in the oval
window, which is an opening of the vestibule and the scala vestibuli of the cochlea. The oval window is located at the bottom of
a deep depression outlined by the facial nerve superiorly, the
promontory inferiorly, the cochleariform process anteriorly, and
the pyramidal eminence posteriorly. The connective tissue lying
between the footplate and the edge of the oval window is called
the annular ligament. A contraction of the stapedius muscle tilts
the stapes and its footplate, and resulting tension in the annular
ligament limits sound transmission into the inner ear to some
extent….

 

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