Middle Fossa Approach to Repair Cerebrospinal Fluid Leak

Brown, Scott

doi:https://doi.org/10.24296/jomi/186

Main Text

The middle fossa approach is indicated for procedures requiring access to the internal auditory canal, structures within the temporal bone, and adjacent structures. This is one of the three main approaches for the surgical repair of tegmental defects causing cerebrospinal fluid (CSF) leak. The middle fossa approach allows for an optimal view of the middle fossa floor for larger or multiple defects, ease of graft placement, and avoidance of the removal of ossicle to access the tegmen. Surgical intervention for CSF leak is indicated when conservative management fails or when spontaneous closure of a defect is unlikely. In this case, a middle fossa approach is used to surgically close a tegmen defect causing CSF otorrhea refractory to conservative management. This case highlights the step-by-step surgical techniques involved in this procedure including the surgical approach to expose the tegmen defect, repair of the tegmen defect using temporalis fascia and a bone graft, and craniotomy repair and closure.

Otolaryngology; surgery; cranial fossa, middle; cerebrospinal fluid otorrhea.

Cerebrospinal fluid (CSF) leaks occur from craniofacial trauma, iatrogenic causes, and other less common etiologies such as neoplasm, infection, and congenital defects.¹ The CSF plays a vital role in providing nutrients to the central nervous system and cushioning the brain and spinal cord. The tegmen is the osseous plate that forms the roof of the tympanic cavity and separates it from the middle cranial fossa. It also separates the subarachnoid space containing CSF from the air space of the middle ear. Therefore, defects in the tegmen can lead to abnormal communications between the subarachnoid space and air-containing spaces of the temporal bone causing CSF leakage.^6,8 On physical exam, patients with CSF leak commonly present with clear rhinorrhea, otorrhea, orthostatic headache, and additional symptoms based on etiology.⁵ For tegmental defect-based CSF leaks, patients may experience clear otorrhea, rhinorrhea, middle ear effusion, hearing loss, and headache.⁶ Serious complications of CSF leakage include meningitis and brain abscess if treated conservatively without surgical intervention.² Surgical treatment is first line for chronic CSF rhinorrhea, posttraumatic patients refractory to conservative or medical management, and patients with significant intracranial pathology.¹ The surgical approach to fixing a CSF leak is dependent on the location of the defect and etiology. For tegmental defects, the middle fossa approach is preferred due to its high success rate and long-term efficacy in control of CSF leak with several advantages over alternative approaches.³

This patient is a 57-year-old female who presented with a complaint of fullness and hearing loss in the left ear. She underwent a myringotomy with tube placement and subsequently had persistent drainage of clear watery fluid from the left ear canal. She was treated with multiple antibiotics and different topical preparations without improvement, and as a result of the persistence of her symptoms, she had a CT of the temporal bone performed, which revealed a defect in the tegmen overlying the mastoid of the left ear consistent with probable CSF leakage into the middle ear and mastoid.

On a physical exam, this patient had exam findings consistent with tegmen defect including clear otorrhea, middle ear effusion, and hearing loss from the left ear.

CT of the patient’s temporal bone showed a defect in the tegmen (5 mm in diameter) overlying the mastoid of the left ear.

The overall prognosis of CSF leaks is favorable especially in cases of craniofacial trauma where conservative management may be all that is required for resolution. However, most tegmental defects are spontaneous, which have a very low rate of spontaneous closure. This means that most of these patients require surgical closure. If left untreated, there is a risk of developing meningitis. Surgical repair of lateral spontaneous CSF leaks has a low average overall failure rate of 6.6%.⁷

There are several treatments for CSF leak depending on etiology including conservative and surgical management. Conservative management is often first line for CSF leak from craniofacial trauma, and these strategies include elevation of the head, antibiotics, and diuretics. Studies suggest that 68–80% of the posttraumatic CSF fistulas can be closed spontaneously within 48 hours and up to 85% closed within 7 days of initial injury.^1,12 Surgical management is considered as first-line treatment for patients with symptoms refractory to medical management for 3–7 days.¹ The location of the defect is the most critical factor in determining surgical approach. There are three main approaches to repairing tegmental defects: transmastoid approach, middle fossa approach, or a combination approach.³

The goal of treatment is to manage persistent symptoms of the CSF leak including CSF otorrhea as well as to prevent serious complications such as meningitis and meningoencephalocele.⁶ In this case, the patient underwent myringotomy and had persistent draining of water fluid from the left ear canal. Additional symptoms included feeling of fullness and hearing loss. She was treated with antibiotics and managed conservatively but had no improvement of symptoms. Imaging showed a defect in the tegmen, which has a low chance of resolving spontaneously. Therefore, surgery was indicated to close the defect in the tegmen overlying the mastoid air space to resolve symptoms and prevent additional complications.

For tegmental defects, the middle fossa approach is the most common and has a low failure rate. Its advantages include being able to see the entire skull base floor in the event of multiple defects or for the placement of large multilayer grafts, and avoidance of removal of ossicles for repair of tegmen tympani defects.^7,8 This approach has been shown to have low morbidity and high long-term efficacy.^9,10 However, this method is more invasive than other approaches as it involves a craniotomy and temporal lobe and dura retraction. Therefore, these patients have potentially longer recovery times and higher risk of epilepsy from the accompanying craniotomy.⁸

This middle fossa approach to the temporal bone was first described in 1891 by Frank Hartley as a route to the trigeminal ganglion. In 1958, this approach was adapted for neurosurgery procedures and was strictly used in that domain until it became more widespread as an approach for the temporal bone.¹¹ This has now become one of the three main approaches to repairing tegmental defects including: transmastoid, middle fossa craniotomy, or a combination approach.³ Its advantages include visualizing the entire skull base floor in the event of multiple defects, optimal placement of grafts, and avoidance of manipulation in the middle ear region such as removal of ossicles.^7,8 This approach has been shown to have low morbidity and high long-term efficacy.^9,10 Several institutional studies have found a high success rate in repair of CSF leak and prevention of recurrence with rates from 91–100% depending on usage of lumbar drains.^3,9 A systematic review of lateral skull base repairs with middle cranial fossa and transmastoid approaches reported a low overall failure rate of 6.6%.⁷

A general anesthesia with desflurane is required for brain relaxation. After prepping and draping the surgical field, an incision of the temporalis muscle in the pretragal area is required to access the temporal bone for craniotomy. A lazy S-type incision should be performed from the tragal area to the area above the ear in a vertical line tangential to the external auditory canal. The initial incision should be carried down through the subcutaneous layer to the level of the temporalis fascia. The superficial temporal vessels in the region anterior to the ear require careful manipulation and may end up being removed. The root of the zygoma is the inferior limit of the dissection. When the temporalis fascia is exposed, a graft can be harvested, cleaned, and set aside. Repairs often involve either autologous temporalis fascia, autologous bone grafts, or alloplastic grafts to repair tegmental defects. Among autologous grafts, temporalis fascia and muscle are easily available and have high efficacy making them popular choices for grafting. A Silastic block can be used to clean the graft and remove residual attached muscle fibers. This also allows the graft to dehydrate and form a flat surface for ease of manipulation. The temporalis muscle is divided up from the inferior end of the dissection at the root of the zygoma in a curvilinear fashion. A cuff of temporalis fascia on the edge of the muscle may be left to make reapproximation easier at the end of the procedure. The muscle can be elevated anteriorly and posteriorly to expose the temporal cortex for the craniotomy.

Next, the craniotomy is typically performed centered approximately 2/3 anterior and 1/3 posterior to the external auditory canal. A craniotomy bone flap measuring 4x5 cm to 4x5 cm on each side is made with a regular drill and cutting burr followed by a diamond burr when down to thinner eggshell consistency bone. Alternatively, a craniotome can be used to raise the bone flap. The bone should be taken down to the level of the dura with the diamond burr. It is critical to expose the dura at all edges to prevent tears when raising the bone flap. Dural bleeding can be managed with bipolar cautery; however, care should be taken to keep the bipolar parallel. When the elevation of the dura using a freer elevator begins, the floor of the middle fossa plate should come into view. A microscope can be utilized to see translucent areas with thin bone to improve exposure. The dissection should continue along the floor of the tegmen and dura from the petrous ridge, which is the extent of the dissection posteriorly. The dissection should continue anteriorly to the middle meningeal artery and foramen spinosum. Defects in the tegmen over the mastoid area can be visualized with this exposure.

Next, the defect should be measured to estimate the necessary size of the bone graft. A small graft is taken from the inner table of the bone flap. The inner cortex of the bone flap should be removed with just the outer cortex remaining. The graft should be shaped to be smooth on all the edges and contoured for the surface of the tegmen. Next, the temporal fascia graft should be taken and divided into two pieces. One piece should be placed over the defect first. The bone graft should be placed over the first layer of fascia. The second piece of fascia should be placed over the bone graft to secure and sandwich it in place. The upper fascia graft should be advanced to get good coverage of the bone graft as well as the tegmen medial to the bone graft. DuraGen can be utilized to hold down the fascia and support the repair. This will form a three-layer repair of fascia, bone, and fascia supported by DuraGen. Gelfoam can be placed to supplement the bigger gaps in the dura.

Specialized equipment includes:

Drill system with cutting and diamond burrs.
Craniotome, if desired.
Stryker Plating System.
DuraGen (collagen-based dural graft).
Intraoperative facial nerve monitoring device (could be used to avoid iatrogenic traumatization of the facial nerve during the surgery).

Author C. Scott Brown also works as editor of the Otolaryngology section of the Journal of Medical Insight.

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.

Citations

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Bernal-Sprekelsen M, Bleda-Vázquez C, Carrau RL. Ascending meningitis secondary to traumatic cerebrospinal fluid leaks. Am J Rhinol. 2000;14(4):257-259. doi:10.2500/105065800779954473.
Hoang S, Ortiz Torres MJ, Rivera AL, Litofsky NS. Middle cranial fossa approach to repair tegmen defects with autologous or alloplastic graft. World Neurosurg. 2018;118:e10-e17. doi:10.1016/j.wneu.2018.05.196.
Oh J-W, Kim S-H, Whang K. Traumatic cerebrospinal fluid leak: diagnosis and management. Korean J Neurotrauma. 2017;13(2):63. doi:10.13004/kjnt.2017.13.2.63.
Chan TLH, Cowan R, Hindiyeh N, Hashmi S, Lanzman B, Carroll I. Spinal cerebrospinal fluid leak in the context of pars interarticularis fracture. BMC Neurol. 2020;20(1):162. doi:10.1186/s12883-020-01740-1.
Marchioni D, Bonali M, Alicandri-Ciufelli M, Rubini A, Pavesi G, Presutti L. Combined approach for tegmen defects repair in patients with cerebrospinal fluid otorrhea or herniations: our experience. J Neurol Surg, Part B Skull Base. 2014;75(4):279-287. doi:10.1055/s-0034-1371524.
Lobo BC, Baumanis MM, Nelson RF. Surgical repair of spontaneous cerebrospinal fluid (CSF) leaks: a systematic review. Laryngoscope Investig Otolaryngol. 2017;2(5):215-224. doi:10.1002/lio2.75.
Stenzel M, Preuss S, Orloff L, Jecker P, Mann W. Cerebrospinal fluid leaks of temporal bone origin: etiology and management. ORL. 2005;67(1):51-55. doi:10.1159/000084306.
Nelson RF, Roche JP, Gantz BJ, Hansen MR. Middle cranial fossa (MCF) approach without the use of lumbar drain for the management of spontaneous cerebrospinal fluid (CSF) leaks. Otol Neurotol. 2016;37(10):1625-1629. doi:10.1097/MAO.0000000000001208.
Braca JA, Marzo S, Prabhu VC. Cerebrospinal fluid leakage from tegmen tympani defects repaired via the middle cranial fossa approach. J Neurol Surgery, Part B Skull Base. 2013;74(2):103-107. doi:10.1055/s-0033-1333616.
Glasscock ME. Middle fossa approach to the temporal bone: an otologic frontier. Arch Otolaryngol. 1969;90(1):15-27. doi:10.1001/archotol.1969.00770030017006.
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Cite this article

Calhoun D. Cunningham III, MD, John Doe, C. Scott Brown, MD. Middle fossa approach to repair cerebrospinal fluid leak. J Med Insight. 2024;2024(186). https://doi.org/10.24296/jomi/186

Procedure Outline

Transcription

CHAPTER 1

This patient is a 57-year-old female, who presented with a complaint of fullness and hearing loss in the left ear. On examination she was found to have a middle ear effusion. She underwent a myringotomy with tube placement and subsequently had persistent drainage of clear watery fluid from the left ear canal. She was treated with multiple antibiotics and different topical preparations without improvement, and as a result of the persistence of her symptoms, she had a CT of the temporal bone performed, which revealed a defect in the tegmen overlying the mastoid of the left ear, and consistent with probable CSF leakage into the middle ear and mastoid. And so she presents today to undergo a middle fossa craniotomy and closure of her CSF leak with a repair of the tegmen from above.

CHAPTER 2

So we're going to start to with a slightly lazy-S-type incision beginning just in front of the ear and right above the tragal area. And we're going to carry this superiorly. Above the ear. And in a vertical line, which is tangential to the external auditory canal, which is - will put us in a good location for getting to the area of the tegmen above the mastoid and middle ear space. Self-retaining retractor. So with my first incision, I've carried this down through the subcutaneous layer to the level of the temporalis fascia. We’re gonna want to harvest a graft of temporalis - another self-retaining retractor, please. Pieces, which we’ll use this to cover the tegmen over the area of the leak. Bipolar please. The superficial temporal vessels are in this region anterior to the ear, so we have to watch out for those. Oftentimes we will end up taking the superficial temporal artery. There is the vein. 15 blade. And now I'm going to continue this dissection a little bit deeper through this loose areolar connective tissue to expose the underlying temporalis fascia, and inferiorly, I want to feel the root of the zygoma. That's going to be the inferior limit of our dissection. Bovie now. And I can now feel the root of the zygoma. 15. And we'll now undermine our flap - skin flap - to provide a little bit better exposure. Both anterior and posterior. Undermine a little bit more to provide good exposure of this temporalis fascia and the underlying bone for our craniotomy. So now we have nice exposure of the temporal area here. This is all of our temporalis fascia. Smooth forceps and a 15 blade. Now we're going to harvest our temporalis fascia graft.

And we want a pretty nice size graft of fascia, so that we can divide it into two separate pieces to cover the area of the tegmen. I’m going to need a Silastic block in just a minute. You can see this is a pretty nice, large size graft. And now a Silastic block. And I’m going to lay this graft out on a Silastic block just to clean it up and get some of these muscle fibers off the undersurface. I usually will take this graft and dehydrate it after spreading it out thin, and that way I can cut it to shape later on and it - as a dry graft, it's a little bit easier to get it in where we want it and lay it down flat before it gets too wet and starts losing its shape. So now we have our graft all spread out and nice and thin.

Okay, next we’re going to divide the temporalis muscle. Bovie please. Again, I'm going to feel where the root of the zygoma is that's the inferior extent of our dissection. We’ll start down low, and we're going to come right down to bone and bring this incision superiorly in a sort of curvilinear fashion. And I've left a little cuff of temporalis fascia on the edge of the muscle here to make it a little bit easier to re-approximate at the end of the procedure. Can I have an lempert elevator, please? And we're going to elevate this muscle anteriorly as well as posteriorly to expose the temporal cortex here. Bipolar pedal.

CHAPTER 3

Our craniotomy is typically centered approximately 2/3 anterior and 1/3 posterior to the external auditory canal. And we will demarcate where we're going to make our craniotomy site right here. For these cases, usually it's about a 4x4 or 4x5 cm craniotomy opening - a little bit smaller than what you would use if you were doing this for say a tumor removal case. Okay - much better. Alright. Whenever you guys are ready, we'll take the drill, and I need a 10 suction irrigator. So for craniotomy, we're going to use a just a regular drill with a cutting burr followed by a diamond burr. The other option would be to use a craniotome to raise the bone flap. Water on. And then we're going to kind of get through most of this cortical bone until we get the bone pretty thin - usually inferiorly and anteriorly the bone tends to be a little bit thinner, and then once we're down to sort of eggshell thin bone, we’ll switch to a diamond burr. Okay, diamond burr now. And a bulb irrigator. And I'm going to continue going around, and I'm basically taking this bone down to the level of the dura now. We can use the diamond to kinda stop any of these small bridging veins from bleeding. Now we - nah, this will work. Nah, it looks more curved, smaller - but this will work. And now we’re going to elevate this flap from the underlying dura. Okay - here’s our bone flap. She has a relatively thin skull. Bulb irrigator now and a bipolar. Want the water off? Yeah, thank you. And then we're going to go to a 7. Do you have the Fukushima suction? Bipolar. And we’ll control the dural bleeding vessels with a little bipolar cautery. And I’m going to need a freer or a J-dissector.

CHAPTER 4

Fukushima suction - actually you know what, let me keep this for just a moment in case we drill off a little bit more. A J - or a freer. So now I'm going to start elevating our dura, and I'm looking for the floor of the middle fossa plate. So I want to feel and actually get down, and I'm feeling - I'm touching the floor now, so there's still a little bit of bone here that we can take back to improve our exposure. But at this point we're going to go ahead and switch over and go to the microscope. And you can see, there are little translucent areas where the bone is very thin. Can I have the drill now? And Marcetta, I'm going to have you - just with a little hand irrigator- do you have like a 20-cc syringe that we can irrigate with? I’m going to have you just drip some water in here while I irrigate. If you can just irrigate for me a little bit. Yeah, that's perfect - just like that. Little bit more. This is just going to just improve our exposure a little bit more. Freer. And now the drill one more time. Okay, now bipolar. That's a big suction. Bipole. You can see, these are a little arachnoid granulations here. We’re going to just cauterize these little areas. That does tighten up this dura and allows it to shrink back a little bit. And now let's go back to the Freer. And I'm going to continue now our dissection along the floor of the tegmen. Posteriorly here, you can see these little almost translucent areas where it gets very very thin, and as we dissect the dura, we want to work from posterior to anterior. So posteriorly here I'm working back towards the petrous ridge. Drill for a moment. It's okay. You don't have to drill. And I'm going to control some of this bleeding here with the drill. Okay. And as we go back, I'm starting - there's a - there's a sizable opening right here. You can see this hole in the tegmen right over the mastoid area.

It’s a relatively good-sized hole too. Continue dissecting this back towards the petrous ridge. Here I'm at the level of the ridge. And she has another small area here with a little bit of a small tiny little encephalocele going down in through there. Anteriorly, we're working - this is to heading towards the middle meningeal artery and foramen spinosum. We’re not quite there yet, but you can see these small little diploic veins here. Bipole. A little bit of bone wax? Some bone wax and do you have - and a cottonoid? And now the cotton pledget. Okay. Take that. We’re going to need a 1 x 1 Duragen also, please. And there is a small little area here with an encephalocele. We're going to come across that in just a moment. Can I have another cottonoid? Big - large one - largest one you have. With this kinda get that blood out of our way a little bit. Maybe actually too small. Here is where her large opening is, and this is all an encephalocele that we're seeing medially here. Bipolar. And that's where she's got her big opening. That may be... Okay, bipole. And we’re going to just cauterize this dural tissue. And basically come right across here. Big opening. Okay, freer now. I'm going to keep working my way back here. I'm on bone, and now we are all the way around it. Here we've come to the... Another cottonoid. And I’m going to need a ruler in a minute. This is the arcuate eminence. Can you lower her head just a little bit? Yep. So this ridge here of white bone, we're seeing, is the arcuate eminence. And you can see her defect is this area just in front - can I have some irrigation now? the bulb irrigator. And so here is our area of defect. We have a little encephalocele here, and we have a hole going into the - through the mastoid tegmen just lateral to us. This white, red bone is the arcuate eminence, so we're lateral to the arcuate eminence just overlying the mastoid area. So can I have that ruler now?

CHAPTER 5

Let’s have a pair of straights - scissors - iris scissors. It’s okay, these will work. And we’re just going to cut this about 2 cm. So now I'm going to get a - just measure just to get an idea of how long we want our bone graft to be. Okay, I'll take that that measure now. So this is 2 cm. This defect is probably a little over a centimeter. So, maybe about a centimeter and a half, a centimeter and a quarter should be good to cover this area. Okay. Let’s now have the overhead lights. Okay, that's working.

Alright, so now we're going to take a small graft from the inner table of the bone flap. She has a relatively thin skull, but if we get about a centimeter and a half, we should be good. Okay. So you want to grasp this with something like a Kelly Clamp, so it's very stable. And I'm going to have you irrigate. And so I'm going to go in and take the inner cortex of our bone flap here. More water. That’s pretty thin. I want you to come… Let's have a Freer. So now we have our bone graft. We’ll save that. Can I have my eye shields off and a mosquito? Now we're going to shape our graft.

We want it to be smooth on all the edges, and also we’ll have to contour it a little bit for the surface of the tegmen. Mosquito and now the diamond burr. And again, I'm going to have - Marcetta if you don't mind, I'm going to have you just irrigate a little bit. More irrigation. Okay, now let’s just check it. We’re going to go back to our surgical field. Now a GK or the bipolars. And this little graft is going to sit down in here. Maybe a little bit still a little bit too long and too wide. Okay, bipolar for a second. Let me have that. I’m gonna need that drill back in just a moment. Now let's have the mosquito again and the drill. So we're going to shape our graft a little bit more. I'm going to kind of bevel these edges, smooth them down so when it lays flat, there's no edges - sharp edges pointing upward into the dura. And this tissue this encephalocele will eventually just shrink up and get reabsorbed. And now the bipole. Okay. So our graft is going to sit… It’s still a little bit… It may actually sit better like… More like that… And that’s probably a little better. Now the - next I need the fascia graft.

And a - do you have a sponge, Marcetta? Do you have like some of those Fukushima forceps, those long forceps? And some straight iris scissors. Without teeth, right? Without teeth. Yes. This has been under a drying lamp. That way we can now trim it the way we want. I'm just going to clean up some of the loose edges on it, so we don't have a lot of frayed edges that we're struggling with. Unfortunately, it got a little wet there. And I’ll divide this into two pieces. One piece we we’ll put down first, and the second piece we’ll place over the bone graft to kind of secure it and sandwich it in place.

Now a - those bayonet forceps. And our graft is going to lay in here like that. Just like that. Now before we put lay the graph down, first I’m going to lay a sheet of fascia down. Let's have our fascia graft. And so we’ll put one layer of fashion down first. Get that laying flat in here. Can I have that little J-dissector now? And can I have some irrigation? And I'm just going to wet this, so we can get it to lay down flat. J-dissector. Yep. So we have our fascia graft, and we’ll spread this out. Lay down, covering everything. That's our first layer. Now, can I have the bayonet? Now we're going to lay our bone graft in place. Move to this area like so. Once this is in place, we're now going to take our second graft and just put it in the - yep, perfect. Now we're going to cover this bone graft with our second fascia graft. Can I have now a - that dissector again - actually, a little bit of irrigation? Now the J-dissector. Now I'm going to advance this upper fascia graft back a little bit, so we get good coverage of the bone graft as well as the - the tegmen medial to our bone graft. And that looks very good. And that is pretty much our repair. Now, is there - do you have that DuraGen? I do. So what I’d like you to do, Marcetta, is take the DuraGen and place it in a fascia press and press it. You able to see that well, Scott? Press the whole thing flat, Marcetta.

And then divide it in two, Marcetta - length - lengthwise with some straight scissors, and then hand me one of those pieces with a - yeah, I guess - actually like a smooth bayonet. Where’d it go? Okay. It's in your hand. And we’ll also put a little DuraGen over this to kind of help support this repair. Okay, take that. Now, bayonets again. Get these out of here without pulling out everything. Okay, that’s one. And two. Okay, and that is it. Now, let’s see that other - that DuraGen - that other piece. I'm just going to have some scissors. What’s the time, Scott? Okay. Alright, the bone flap now. And can I have some eye shields?

CHAPTER 6

And that is our three-layer repair of fascia, bone, and fascia. Can I have plates, please? Okay. Okay, now a screw - what’d you think? Another one. Alright, some - a little bit of pickups and a little GelFoam. Let’s have a - do you have a dry sponge? We’ll need to press that out. Some larger ones are good. I don't know if it matters, Scott, but I tend to I like to put a little GelFoam where you've got a bigger gap in dura sitting right there, so there's just some layer between the muscle and the dura. And like I said, it probably doesn't really make a big difference but... What's that? Yeah. Everywhere - I mean in the rest of the flap, it's pretty close - bone-on-bone - but we drill off a little more down low, so I think it just offers a little - a little protection there. Okay. Now the stitch. And a pair of pickups.

CHAPTER 7

[No Dialogue.]

CHAPTER 8

And then I may need some instruments of our pic tray, our regular ear tray. Wow, a lot of CSF in her ear. Of course a lot of that’s probably now irrigation fluid. She does still have a PE tube in place. Can I have a right angle?

So here is the original tube this patient had placed - well... Yeah. Can’t tell if that’s an Armstrong or a Shehe, it does not come out easy. Do you hold that - do you have that next size up hook? And a 3 suction. So Scott, these - these are - I… Yeah, and just for - just a side - I don’t ever use these Armstrongs for a plastic tube cause they are - for that reason there - they are a a bear to get out if you have to take them out. And they they don’t fall- I mean it’s good in some kids if you don't want it to fall out, but they don't fall out that easy, and then, you know, if they don't come out, then you - you risk getting perfs. Yeah - no, no - that’s a Sheehy, fluoroplastic. No, the Armstrong has a bevel, don't they? Yeah, the Armstrong has a bevel. They do come out a lot easier. I just don't like fluoroplastic tubes. I don't like - I like Silastic tubes. But see how there's kind of granulation, and it's bleeding a little bit? That's good cause it'll help this to heal up. So just kind of clean around it and make sure we don't see any kind of stuff in the ear. Okay, can I now have - did we make a paper patch? Do we have a paper patch? Gosh is that the...I think we just use this.

Let’s have a pair of curved iris scissors. And now a - like a little pair of alligators. Still a little bit big. And I’m going to then put a little few pieces of GelFoam over the top of it. We don't have floxin there, do we? Is there any in the room? Now I'll have that footplate hook? Okay. Floxin. Can I have a gimmick? It’s okay. I’m not putting that much more in - just enough to kind of pack that - just to hold it down on there. Suction. Do you have another dry sponge? Press that a little bit more. She probably won't like that her ear is all plugged up, but it won't be running after today. And that’s it.

DOI
Publication Date	2024/08/12
Article ID	186
Production ID	0186
Volume	2024
Issue	186
https://doi.org/10.24296/jomi/186