Revision Canal Wall Down Mastoidectomy with Mastoid Obliteration
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Table of Contents
Revision canal wall down (CWD) mastoidectomy with mastoid obliteration is most often performed to manage persistent otorrhea and debris accumulation in the mastoid bowl following CWD mastoidectomy. In this case, obliteration is performed for persistent otorrhea from the mastoid bowl and revision CWD mastoidectomy is completed to address a new retraction pocket following a prior CWD mastoidectomy for chronic otitis media with cholesteatoma in a 23-year old male.
There have been numerous reported techniques used for mastoid obliteration, and in this case, a posterior periosteal flap is made, and the mastoid cavity is filled with autogenous bone paté. Following obliteration of the mastoid, a perichondrial graft is used to cover the area. In this case, a titanium total ossicular reconstruction prosthesis is used to rebuild the ossicular chain, and a second perichondrial graft is used to reconstruct the tympanic membrane. The canal is packed with Gelfoam to secure the fascial grafts in place. Postoperatively, patients are typically advised to remove their head dressing 24 hours following the surgery and to apply a topical antibiotic ointment daily to a cotton ball in the ear.
Mastoidectomy; bone paté; CWD; mastoid obliteration; COM; cholesteatoma.
Revision canal wall down (CWD) mastoidectomy with mastoid obliteration is most often performed to manage persistent otorrhea following CWD mastoidectomy for chronic otitis media (COM) with or without cholesteatoma.1,2
The goal of the initial mastoid surgery is to create a dry, safe ear and preserve as much hearing as possible.3 The primary indications for mastoidectomy include cholesteatoma or neoplastic extension into the mastoid and relative indications are a history of profuse otorrhea, tympanoplasty failure, and tympanic membrane perforations requiring a greater degree of exposure.4 The options for mastoidectomy include a simple/cortical mastoidectomy, intact canal wall/complete mastoidectomy, CWD/modified radical mastoidectomy, and radical mastoidectomy. Primary mastoid obliteration in course of CWD mastoidectomy enhance long-term outcomes, reducing the need for secondary revision procedures, and improving overall ear stability and dryness. Numerous studies have demonstrated that the use of bone paté as a safe and effective method for obliterating the mastoid cavity either at the time of original CWD mastoidectomy or if revision procedure is required.26–28
A simple mastoidectomy involves the removal of the mastoid cortex and underlying air cells and is generally performed to drain an acute mastoiditis with subperiosteal abscess.5 A canal wall up mastoidectomy involves the removal of additional mastoid air cells lateral to the facial nerve as well as the bony portion of the otic capsule with preservation of both the posterior and superior walls of the external auditory canal.3 A CWD mastoidectomy also involves air cell removal but in this case the walls of the external auditory canal are removed to afford increased exposure of the mesotympanum and epitympanum with the ability to resect middle ear disease and reconstruct the necessary components of ossicular chain in one surgery.6 A radical mastoidectomy involves the complete exteriorization of the middle ear and mastoid air cells to form a single cavity and this is reserved for patients with irreversible middle ear disease or unresectable cholesteatoma or neoplasms.7
In this surgical case, a revision CWD mastoidectomy with mastoid obliteration and middle ear reconstruction is performed in a 23-year-old male with persistent otorrhea from the mastoid bowl and a new retraction pocket following a prior CWD mastoidectomy for COM with cholesteatoma. The use of picture-in-picture offers our viewers an endoscopic view of the relevant surgical anatomy and key steps of the procedure.
A 23-year-old male with a history of chronic otitis media and cholesteatoma of the right ear with prior CWD mastoidectomy presents with a chief complaint of recurring discharge from the mastoid bowl over the past several months. This discharge is difficult to control despite frequent cleaning and the use of topical antibiotic powders. Otoscopic a new retraction pocket had formed posterior to the remnant of the tympanic membrane and anterior and deep to the head of the malleus.
Mastoid obliteration is indicated for patients with persistent otorrhea following a CWD mastoidectomy that does not respond to frequent cleaning of the mastoid bowl or topical antibiotic therapy.1,9 The role of surgery is to reduce the size of the cavity and while it is ideally performed at the time of the initial CWD mastoidectomy, it may be performed as a secondary revision procedure.
As discussed previously, the primary indication for mastoid obliteration is for chronic middle ear disease following CWD mastoidectomy. However, there are additional indications for the surgery including translabyrinthine acoustic neuroma resection, cerebrospinal fluid leak, temporal bone resection for neoplasm, and extensive temporal bone trauma.1,2
An indication for mastoid obliteration along with the entire middle ear and eustachian tube is for prevention and management of CSF leak following translabyrinthine acoustic neuroma resection.10 In addition, it may also be used to manage CSF leak from meningoencephalocele, severe temporal bone trauma, or even spontaneous CSF otorrhea.11–13 Malignancies that require lateral, subtotal, or total resection of the temporal bone will also require tympanomastoid obliteration irrespective of whether or not there is a concomitant CSF leak.14
Unique situations requiring mastoid obliteration prior to cochlear implantation include patients with a history of chronic otitis media (COM) or labyrinthitis ossificans, where an extensive drill-out with removal of the posterior canal wall is necessary. These patients will also require mastoid obliteration following mastoidectomy to prevent infection of the electrode array in cases of COM and to ensure adequate surgical access in cases of labyrinthitis ossificans.1,8,15
The procedure is generally performed under general anesthesia and local injection of 1% lidocaine with 1:100,000 epinephrine for hemostasis is completed via a 27-gauge needle in the posterior-superior ear canal to allow for vasoconstriction of the “vascular strip”.16,17
A 1-mm knife is used to make one incision at 12 o’clock and another at 7 o’clock to define the locations of the vascular strip. A 15 blade is then used to make a postauricular incision to develop a fascial plane from which to harvest the temporalis fascia. A large amount of fascia is harvested and placed on a Silastic block prior to trimming the excess muscle fibers and shaping the graft for lining the bone paté and completing the tympanoplasty.
A periosteal flap is then elevated to expose the retromastoid bone that will be used to harvest the bone paté for the obliteration. The bony area superior to the squamous aspect of the temporal bone is also used for harvesting.
A large cutting burr is used to produce large, uniform bone paté particles that are collected in the Sheehy bone paté collector. A wire-mesh sleeve in the device collects the particulates while allowing any irrigants to pass through easily. The burr is used along the cortex of the mastoid as well as the squamous temporal bone. Care is taken to avoid entering the air cells to minimize the risk of collecting either epithelial cells or bacteria. Collection stops just prior to exposure of the air cells, and the collected paté is soaked in ofloxacin topical antibiotic ear drops and covered with a damp sponge prior to setting it aside.
The lining of the mastoid is elevated using a Freer and a 15 blade to obtain exposure of the middle ear anatomy. This process begins posteriorly with the periosteal flap and continues to the facial ridge. Following adequate exposure, the relevant anatomy is visualized including the remnants of the tympanic membrane, malleus, and incus.
Elevation of the tympanic membrane is attempted with insufflation of nitrous oxide; however, the membrane appears to be adherent down to the footplate. An inferior incision is made with a 1-mm knife to elevate a tympanomeatal flap and obtain access to the middle ear. A 3-mm suction and round knife are used to carefully elevate the tympanic membrane superiorly. In this case, the jugular bulb is observed in a high-riding position with superficial bony dehiscence and is delicately avoided. In the process of elevating the tympanic membrane from its collapsed position on the cochlear promontory, the chorda tympani is visualized and sacrificed due to its proximity to the retracted drum. Bellucci scissors and a round knife are used to remove the excess skin debris in and around the mastoid. The tensor tympani tendon is sacrificed as well. A dehiscent facial nerve is identified at the first genu prior to heading towards the geniculate ganglion and the facial nerve stimulator is used to assess the nerve function. The remainder of the annulus is elevated.
The mastoid is saucerized with a diamond drill, and a bulb irrigator and suction are used to cool the surface throughout this process. The surface is contoured to create a rounded shallow mastoid bowl, which will be easier to pack with the bone paté. Any remaining skin is removed via drilling and the surfaces are polished with careful attention to the anterior epitympanic space. The sigmoid is skeletonized with caution taken around the tegmen. Any bleeding is controlled. Cartilage for the tympanic membrane restoration graft is harvested.
Additional perichondrium is harvested to reconstruct the tympanic membrane as well as to prevent extrusion of the titanium total reconstruction prosthesis that will be used. The prosthesis is sized. Gelfoam and Amerigel are placed underneath the tympanic membrane remnant.
Proper coverage of the dehiscent facial nerve is essential to prevent postoperative facial nerve palsy and ensure optimal surgical outcomes. Various materials and techniques are used to cover and protect the nerve, including autologous materials (fascia, cartilage, or bone paté), bioactive glass, and alloplastic materials such as silicone slices or hydroxyapatite cement. These materials are chosen for their durability and ease of use. Before mastoid obliteration with bone paté, we cover the dehiscent facial nerve using gel film to minimize the risk of facial nerve damage and reduce scarring. Although the bone paté will also cover the dehiscent facial nerve, double protection is important. The mastoid is completely obliterated with bone paté. Careful attention is necessary to keep the bone paté dry by blotting with the cotton tip applicators and suctioning when necessary.
The fascia graft is then shaped and prepared for placement. A Rosen needle is used to slide the graft underneath the remnant tympanic membrane, and the inferior tympanomeatal flap is then secured over the graft to complete a medial underlay tympanoplasty. A titanium Alto total ossicular reconstruction prosthesis (Grace Medical) is adjusted to the appropriate length (4.5 mm) by ratcheting the platform up and down on the prosthesis stem. A trimmer is used to remove the stem of the prosthesis. The prosthesis is then positioned with its head placed just medial to the cartilage graft, and the longer, thinner foot inserted into the stapes footplate at the oval window. Additional Gelfoam packing is applied to secure the graft and prosthesis in place.
Additional Gelfoam is applied to cover any areas of exposed bone paté. The vascular strip, created at the beginning of the procedure, is then placed flat against the posterior canal wall. The overlying fascial layer is anchored to the surrounding fascia, covering the remainder of the bone paté and providing a strength layer for incision closure. After securing the deep fascial layer, the overlying skin of the ear is loosely reapproximated to close the postauricular incision. Finally, the canal is packed with additional Gelfoam.
Mastoid obliteration to address a mastoidectomy defect has been performed since the early 20th century with the original technique first described by Mosher in 1911.18 Over the last century, a range of approaches have been used to obliterate the mastoid cavity including muscle, periosteal, or fascial flaps as well as free grafts/ceramics (bone, cartilage, hydroxyapatite), and even the combination of the two strategies as introduced by Palva in 1978.19–24 In this case, an autologous bone paté in combination with an inferiorly based fascia graft was performed to complete the mastoid obliteration.
As proposed by Takahashi et al in 2007, a key advantage of using bone paté is that it minimizes the likelihood of pocket formation as it can be shaped smoothly against the exteriorized surface of the mastoid cavity.25 Numerous studies have demonstrated that the use of bone paté as a safe and effective method for obliterating the mastoid cavity either at the time of original CWD mastoidectomy or if revision procedure is required.26–28
Askar et al. (2019) report on mastoid reconstruction using platelet-rich plasma (PRP) and bone paté after CWD mastoidectomy. Involving 21 patients, the study found that PRP and bone paté led to good healing outcomes, with no cases of external canal stenosis or mastoid fistulas during the 12 to 16 months follow up. The reconstructed mastoid cavities were smooth, well-aerated, and had minimal complications.30
Bernardeschi et al. (2017) evaluated the use of bioactive glass S53P4 for mastoid and epitympanic obliteration in 41 patients. The study found significant improvements in hearing, well-healed anatomical structures, and enhanced quality of life, with minimal complications. Bioactive glass S53P4 proved effective for mastoid and epitympanic obliteration.31
Pontillo et al. (2023) evaluated the quality of life (QoL) after revision CWD mastoidectomy with mastoid obliteration in cholesteatoma patients. The study found no significant difference in postoperative QoL between those who underwent revision CWD and primary CWD with obliteration.32
Given the heterogeneity in the surgical options as well as the lack of standardization in reported outcomes from each case series, it is difficult to determine an ideal procedure, material, or timing for mastoid obliteration. In fact, a recent systematic review of all available mastoid obliteration and reconstruction techniques reported in the literature suggests that there is a specific lack of uniformity in reporting auditory outcomes, quality of life improvement, and imaging studies for evaluation of postoperative disease.29
Future prospective work is necessary to evaluate the efficacy of mastoid obliteration in comparison to repeat CWD mastoidectomy on prevention of recurrent mastoiditis agents on the rate of healing and surgical outcomes.
Meatoplasty is often performed in conjunction with CWD mastoidectomy for several important reasons:
- Improved access and ventilation, which helps in maintaining a dry and healthy mastoid cavity, reducing the risk of infection.
- Enhanced drainage by widening the ear canal.
- Reduced risk of stenosis of the ear canal.
- Ease of follow-up care to manage and monitor the surgical site.
However the decision to forgo meatoplasty following revision CWD mastoidectomy with mastoid obliteration was based on several considerations:
- Anatomical Preservation: By not performing meatoplasty, we aimed to preserve the natural anatomy of the external auditory canal, which can be beneficial for postoperative healing and patient comfort.
- Obliteration Technique: The mastoid obliteration technique employed in our study utilized autologous materials, which effectively reduced the size of the mastoid cavity and minimized the need for additional surgical modifications such as meatoplasty.
- Postoperative Outcomes: Our clinical outcomes indicated that the obliteration alone provided sufficient stability and dryness of the ear, with no significant cases of chronic otorrhea or cavity issues that would necessitate meatoplasty.
- Patient-Specific Factors: Each case was evaluated individually, and the decision was tailored to the specific anatomical and clinical needs of the patient. In instances where the external auditory canal was adequately sized and the obliteration was successful, meatoplasty was deemed unnecessary.
We believe that this approach optimizes surgical outcomes while minimizing additional surgical interventions. Further studies and long-term follow-up will continue to inform and refine our surgical strategies.
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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- Canal Wall Reconstruction (Mastoidectomy). Iowa Head and Neck Protocols. Accessed April 25, 2021. Available at: https://medicine.uiowa.edu/iowaprotocols/canal-wall-reconstruction-mastoidectomy.
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Cite this article
C. Scott Brown, MD, Prithwijit Roychowdhury, Calhoun D. Cunningham III, MD. Revision canal wall down mastoidectomy with mastoid obliteration. J Med Insight. 2024;2024(187). https://doi.org/10.24296/jomi/187Procedure Outline
Table of Contents
- Transcanal Anatomy
- Transcanal Injection
- Canal Incisions
- Postauricular Incision
- Harvest & Thin Fascia Graft
- Periosteal Elevation
- Cartilage Harvest
- Prosthesis
- Middle Ear Packing
- Fascia Grafts Design
Transcription
CHAPTER 1
This patient is a 23-year-old male with a prior history of chronic ear disease and cholesteatoma involving the right ear. He has previously undergone a canal wall down mastoidectomy, however, has had persistent problems with recurring discharge from the mastoid bowl - and on recent followup was found to have a new retraction pocket that had formed behind and anterior to the head of the malleus. And so, he is undergoing a revision canal wall down mastoidectomy today, and we're going to obliterate the mastoid using autogenous bone pate. Part of this surgical procedure will also involve revising the previous drilled mastoid cavity and removing any areas where potential retraction of the eardrum can occur. That's your bone. That's the dust collector. That's a - that's a Sheehy bone pate collector. Lorna, here's your injection back. Can I have the scissors one more time? I always want to make sure this is going away. So, did you hear that? Do you have the - do you have those Mayo scissors? Alright, and irrigation and suction. His eardrum is pretty retracted, and so we're going to add a little nitrous oxide to try to elevate the drum a little bit. No, I think it - I think it's - it's the actual suction in here. He has a canal wall down mastoid cavity. And the mastoid cavity itself today is relatively dry. It's very important prior to operating on these patients - to try to get things as dry as possible, so he was treated with some topical antibiotic powders prior to surgery to try to really clean up the ear. And so, here we see his mastoid cavity, which is pretty well epithelialized, and as we look to the right, this is the facial ridge coming down this way. And there is some remnant of the eardrum up here, and this is the issue - is that he's got a retraction pocket going posterior to this drum remnant up in - up back this way. This is an incus remnant here, and the remnant of the malleus is what we're seeing in front of us here. Can I have a alligator with teeth? Lorna, let me... He's got like this big... Is it working? Yeah, this one's working okay. Can I have the injection now? So he - so let - let - Lorna, let me have a Gimmick for a second.
So here we have - this is the anterior half of the eardrum, malleus handle. This is all a posterior collapse and retraction of the eardrum on to the promontory. Here's the round window niche, the oval window, and looks like the stapes has previously been eroded. There's the cochleariform process, footplate of the stapes, and the drum is refracted right down onto the footplate. Injection now.
CHAPTER 2
Whitney, what are we doing about - I mean, is there anything we can do to... Well, depends on what room you want to have it in because 9 is taken, 19 is taken, 10 is taken. The only other option is CAC 7, which is terrible. I mean, can we get a second room? 7's not horrible. It's just long. Okay, now - I imagine you don't - so, this is the - this is the normal posterior margin of the eardrum. This is what's left of the buttress of the incus. The head of the malleus is up here, superiorly. And we are going to make an incision at the 12-o'clock location here and then inferiorly at approximately the 7-o'clock location to define areas of where our sort of vascular strip would be. 1-knife.
And so, we'll start up top here and come all the way out laterally. One, two, three. And then along the floor of the canal. Okay, Lorna - that 1-knife again. One, two, three. Can I have a 6400? And we come back up top. Suction for a second. Take that 64. Okay. 6400 back. And we've now made our cuts through out over the bony junction. Okay. Now we're going to go behind the ear for our postauricular approach.
15 blade. We'll try to use his original incision, and we usually will need a fairly good-sized piece of fascia to cover the bone pate and the mastoid. So we're going to look for temporalis fascia superiorly. He looks like he does still have some fascia here. Bovie. That's fine. Okay, self-retaining retractor, and then a pair of Metzenbaums. Senn retractor.
I guess we don't have a choice, do we? Well, I know I had one day where I had two pair on one set. I really need a pair actually, but that's - okay. Want me to see if Dalm can find one? Yeah, I mean if she can, that would be great. Let's have a 15 now. So he actually has a fair amount of temporalis fascia that has not previously been harvested. Lorna, can you hold this? So we're going to take a large fascia graft. Smooth forceps and Metz. Lorna, if you want - yeah. Actually, let me get some of this off. And this way. Okay Lorna, come over here. Hold straight up. What's that? She asked what it looked like. Okay, now come all the way over here. Okay, now can I have a Silastic block. But no scissors, huh? And a dry sponge. Scissors. You just getting the rest of muscle fibers off? Yeah, at this point we're going to clean all these muscle fibers off the rest of this fascia graft. So we're going to need enough fascia for repair of the eardrum as well as lining the bone - bone pate, which is used to fill the mastoid cavity, so that's why we use such a large graft for this. Now Lorna, can I have the Bovie, now?
I'm going to feel where the mastoid cavity is prior to making my mastoid periosteal cuts so we don't go into the mastoid. I'm going to start just above the mastoid - barely cut straight down to the bone with the Bovie and then posterior to the mastoid cavity towards the tip of the mastoid. Now a Lempert. And I'm not going to actually enter into the mastoid yet, but I will expose a little bit more of this mastoid bone posterior to it. And the next step which is we're going to harvest our bone pate to fill in the mastoid cavity. So I'm elevating this just to the edge of the mastoid, but I don't actually want to get into the mastoid at this point or I might get into the skin lining of the mastoid. And then we're going to elevate posteriorly and expose a lot of this retromastoid bone, which we'll actually harvest for our bone pate, as well as bones superior over the area of the squamous. Pickups with teeth. And next I need two towels.
CHAPTER 3
Well, let's hook up the bone pate collector. Can I have two Allis clamps and some eye shields, please? So the nitrous I turned on because I was going to - I want to see if it'll elevate that collapsed portion of the eardrum, which might make the dissection a little bit easier. But it looked pretty adherent, so I'm not sure how much it's going to come up. Okay. Can we now have a - can I please have a Senn retractor? And Lorna, I'm going to have you help me out here. If you'll just... Okay, hold that. Water on. And the main thing with this Sheehy bone pate collector is that it stays upright. Water down. Not sure our suction's - I think the problem is our suc - is this - which suction are we hooked into right now? I just got to make sure it's going to be strong enough to suck up the bone. Okay - because the one in the room's still not working well? Well, we can retest it. I think it's - sounds like it's sucking good. Alright. So all that bone dust will be collected in there - just so you know. Lorna, well, I guess it's suck - I'm just worried that this thing isn't... Well, we can open it up and check it. We'll check it. So we'll look at it in 20 minutes. Yeah, but it's - it's just so weak guys. I... So we're just drilling off some of this cortical bone. We'll use some of our irrigation. I doubt they'll give us another room for that. Lorna, can you take your other hand and hold this little flap back right here? Hold what? This little muscle flap - just with your - if you have like a - yeah. Just something to kind of hold that back. Perfect. Okay. That might be good. Go back like this. Let's - we're going to have to... Take this off. Yeah. And then he's going to look in there to make sure he's got it. Can you take the suction off. Hold on one second. Don't turn it upside... yeah, but I like to - I like to get the fluid out of there. Take this off. And here is our bone pate, which we have a very nice amount. And then with this - we get rid of this pink gunk and use this... Take that. You can take the - the bone pate collector now. So we'll want to get rid of this tubing, and we're getting rid - I'm sorry, and we're getting rid of this tip. Here's your scr - your screen. And then I need some Floxin. And this is ofloxacin antibiotic. Do you have anymore? I'd have to get some more because I've got one of these. So we take our bone pate. The bone pate is soaked in ofloxacin topical antibiotic ear drops and then covered with a damp sponge until later use. So the bone pate is now soaked in ofloxacin topical ear drops and then covered with a damp sponge. Now, can I have a Freer? It's in your hand. Got it. You know, when that stuff came out white, I said that's not... And so now we're going to go ahead and get into the mastoid cavity, so
CHAPTER 4
I'm carefully elevating the lining of the mastoid, starting with our periosteal flap posteriorly. It is pretty adherent. And our goal here is we want to elevate this lining of the mastoid intact if possible just to avoid any chance that we're leaving any skin behind in the mastoid, and once we've elevated this lining, we'll also create a flap, like a vascular strip type flap, to cover the bone pate as well. Can I have a pair of - pair of pickups and a Bovie, please? Bovie. Okay, now self-retaining retractor. Another one. Okay - nope, nope - don't do that. Now, can I have the Freer back? And we're going to keep elevating our lining. This is going deep into to the mastoid, and at some point, we'll transect this lining. But we'll never get back to that suction again. Usually, we'll try to take this all the way to the facial ridge. And then we'll just come across. Probably. I'm going to continue elevating this lining out of the mastoid. It's starting to tear there, so there's a little bit of skin collecting here. Let's now have a 15 blade. So now I'm going to actually transect this canal skin. Hold that for a second, Lorna. So smooth forceps and that 15 blade back. And so I'm actually going to use this, bit of the mastoid lining, to create a vascular strip to cover the posterior canal wall and the bone pate later. This little area here. And we will have to actually free this up a little bit. Let's have a - let me have a 15 blade. I'll actually bring this down a little bit. Trim off a little bit more of this tissue. Bring this up. So, this will actually become are lining also. It's got a little hole in it, but that'll be okay. But that will help us line this mastoid. Okay. Now, hold the ear forward, please. So it's - so basically, I kind of created almost like a vascular strip. So once we fill in - we re - we redo the mastoid, this will lay down and cover that, the posterior canal wall. It does - it has a small hole in it, which - let's see, pull on that ear. But some of your fascia may be lying there too. Well, the fascia is going to be covering all that, so... That will go - that will go on top of the facia? The reason for that is to try to help promote epithelialization of the fascia, which is covering the bone pate, so it'll help with that - that aspect of it. And now, let's have a pair of scissors again. I'm actually going to excise a little bit of this stuff. Can I have a 6400? Table away please a little bit. And you all can turn the nitrous off at this point. Okay, that's good. So I'm actually going to come across right here. Brittany, will you scan the 100 and 3 on the 4? Okay. Hold that. Wipe. And so that you can see - wipe. What you can see is there's this deep retraction going superiorly above the eardrum up here. Here's the - what's left of the incus and the head of the malleus. Manubrium is here - drum remnant anteriorly there. And then all of this is just retracted, so now the next step is we want to elevate all this skin lining out of here and get this drum up so we can then reconstruct the eardrum and potentially place the prosthesis. Can I have a large round knife, please?
CHAPTER 5
But here we've gotten all of this lining up very well out of the mastoid. So we're going to continue elevating the mastoid skin. And can I also have a 1-knife, please? Now I'm going to make an incision inferiorly also to create sort of a tympanomeatal flap, and that will allow me to get into the middle ear down low here. And once I'm behind and underneath the eardrum, then we'll start elevating that eardrum superiorly. Can I get a 3 suction, please? Larger and smaller. The large round knife. Yeah, I'm going to save all the anterior part of the eardrum. This stuff is pretty stuff back here. There's some new bone growth underneath the drum inferiorly here, but I want to try to preserve as much of this as we can. So now I'm actually behind and underneath the drum, and then once we're underneath, we want to work our way forward. He's got a little bit of a high - let's have a - you have a 1-knife? He's got a high jugular bulb actually, which looks dehiscent to me. So we'll be fairly cautious of that. 1-knife. So this is the jugular bulb, which we see underneath this little bit of bone here. So I am going to be - try to be as delicate as I can. Could get into a little bit of bleeding. Sometimes you see that the jugular bulb ride up high like that, and as you're elevating the annulus inferiorly, you can get into that. Good. Can I have a pair of cups to the left? I just want to get these little bones segments out of here. Okay, now a Crabtree retractor. Is this the large or the small? Large? Can I have a small one. I think that's maybe the bony covering that used to be over it. This inch of it is kind of strange. We'll actually leave that bone there because it is protecting it a little bit. A small Crabtree, yes. So you got that one - just a little bit shorter. Wow, it's way shorter. And we're going - we need to elevate this up and over the - off of the promontory, which we're seeing the promontory bone here. Can I now have a large round knife? I'm going to continue elevating this mastoid bone and skin. So there is a remnant of - there's the chorda. Can I have a - and I'm going to go ahead - and I am actually going to take the chroda because we are going to need to take all this bone down here. And the drum is retracted all around the chorda, and I think it's very difficult to try to get that drum off of the chorda without stretching it and running the risk of causing symptoms related to the chorda being irritated. Bellucci's to the left. Now a - a - that - let me have a House curette. Okay, now a - that large weapon again. That is most likely facial underneath this superiorly there. We're going to keep elevating. We want to get all of this retracted drum off of the promontory and out of the oval window. That's the round window niche. Can I have a 1-knife now? And there is no stapes. Here is the - the stapes footplate down here. And it is mobile. And I'm going to bring this back just to get an idea of where this - how far anterior this is going - this retracted eardrum. But at some point, we're going to actually excise all of this away. Okay, now can I have some - can I have Bellucci's to the left? This skin is now kind of in - getting in our way, so we're going to just trim all of this out of here. Can I have a large round knife? Bring all this skin down to get this out of the mastoid. Here we go. And we want to make sure we're not leaving any skin remnants behind in the mastoid - let me have a pair of straight Bellucci's. I'm going to give you - this is skin debris here. It's just trash. Take a sponge and wipe that, please. Okay, large weapon, please. And this is the area that was giving him difficulty. He has this pretty deep retraction behind the head of the malleus, and whenever he would get moisture in the ear, this would get infected and inflamed and was causing the issues. Now, the malleus - there is a malleus remnant here, but this is really not serving a - much of a purpose, so I am going to actually get rid of the malleus. We won't need this for our reconstruction. Let's have a - a 5910, please. And I'm going to come in just ant - the anterior edge of the malleus and incise and bring this straight up to meet where our previous incision was, and then I'm going to continue this elevation inferiorly. There's our dehiscent jugular bulb. Can I now have a pair of straight Bellucci's? I will try to preserve - I - we'll remove anywhere where this drum is folded in, but we'll try to preserve a little bit of this posterior skin flap here. Assuming I now cut this. Okay. Can I have Bellucci's now curved to the left? Now a Crabtree disec - or - yeah, a Crabree or a 1-knife actually. I'm going to continue getting this skin up off the promontory, bringing this one around. Facial nerve feels like it is covered with bone here. There's still some retracted drum, which goes pretty deep. And then can I have a small Crabtree? We're going to elevate this superiorly. This is the cochleariform and the tensor tympani. Appears to still be intact. And then - okay, so there is retracted drum going sup - superiorly. There's our tensor. Can I have a pair of - can I have a 5910? And so now I'm just - I am going to actually transect the tensor tympani tendon. Belluchi's. Or actually - you know what? Can I have a small weapon? We're going to need a - an Alto total pros - is this a small or a large? That's a small. So this looks like it may be dehiscent facial nerve. Do we have a facial nerve stimulator? That we're seeing right here - right at the first genu. Facial nerve - but it's dehiscent. Can I have a 1-knife, please? Scott, do you say that? This is all facial nerve here. So that's the kind of first genu heading to geniculate. That's all uncovered there. I assume that's probably just from disease - I mean, just from the skin. I doubt that was done surgically. But the concerning thing is we got to - we have to make sure we're getting all this skin popping out of there. That's bone there, so I'm back on bone right here. This is the area where it's pretty to dehiscent. May be geniculate there. Table away, please. Keep going - a little bit more. Okay. We're bringing this one around, and I'm going to try to connect up here with this area. There is still skin up under here that we need to get out, and some of this we will better exposed with the drill. We'll have to take some of this down. So now, let's have a 1-knife. We have - if we look at what we're seeing now, we've got our round - round window - I'm sorry, oval window - with the footplate of the stapes. This is a cochleariform process - horizontal segment of the facial nerve over the oval window. This is all bone, but then we have this fairly significant area of dehiscence right at the first genu and then heading towards geniculate ganglion here. Building our graft under here. So Scott, down here, we just need to get a little bit more of this elevated so we can get our graft underneath it, but this dehiscent bulb is not exactly making our job easier. Okay. Can I have a - can I have a small weapon now? Strange - why that's all eroded. Can I have a pair of Bellucci's? Can I have a 1-knife now? Can we put it on 0.2? Oh, that's too high. 0.2 please. So we get nice stimulation of the nerve there. Can I have a pair of cups now? And then I need the drill. I'm going to change your suction before you start going. What size do you want? I put a 10 on here. What do you want? That's good. So now we have all the skin out. We want to recontour our mastoid cavity. Yeah, actually let me - let me have that round knife one more time. Let me do one thing before we - we start that. I'm going to actually back elevate this skin a little bit because we're going to smooth down this bone and also elevate our annulus a little bit here. Okay, drill.
CHAPTER 6
You know, we're going to saucerize this mastoid. Lorna, can I get a little more irrigation? Water off now for a second. Water on. Water on guys. Alright, now can I have a bulb irrigator? And now I want to go to a - a 7 suction irrigator and that 4 diamond. One more of the - of these irrigators. And Whitney, I'm probably going to need a 3 diamond also. You can go - if you can go ahead and get that, that would be great. Water down. And we're going to continue just smoothing down the contours of our - water down a little bit, please - of our mastoid cavity. I'm going to take down this remnant of the buttress here. That your cotton ball? Here's your cotton ball. Water down, please. Oh - don't do that. Smooth this down a little bit more. We're going to keep lowering this facial ridge a little bit, but... Bipole. Bipolar. And you all aren't running nitrous now, right? No, sir. Okay. Drill. Water on. Water on, please. Okay. Now I'm going to polish the most of this bone in the mastoid just to make sure we're not leaving any skin remnants behind. Water down a little bit. A little bit more water. Sorry guys. Water down? No, no. More water. Do you have that 3 diamond now - and a 5 suction irrigator? What do you think? Looks good so far. Does that make sense - what we're doing? Yeah, I mean, I guess my question is when you're - when you're going back and just kind of polishing over and examining, are you trying to extend it and do like a full open again or...? Yeah, I mean, I am trying to create a - a sort of more rounded shallow bowl because it'll - it makes it easier for that bone - for you to pack the bone pate. Yeah. So I - but I'm all - I'm also just checking - I'm drilling to make sure that - you know, the - like in these little areas down here, that I haven't left any skin. I mean, the skin came out very easily, but you want to make sure that - like the one area where - where questionably there could be is sort of up in this anterior epitympanic space here because this is where it got really kind of stuck in there. So like right in here - it's important to really polish this spot. Like that's probably skin right there actually. But I am limited a little bit because my facial is all dehiscent there, but I think we can get right down in there without... But anywhere there's like an overhanging ledge where you can't kind of see under it, is a space you want to be concerned about. And this is all okay. But I'm - see how I'm kind of bringing this all the way out from medial to lateral? I'm just creating kind of more of a flat surface as opposed to having these little recesses in here, and that's by getting pretty thin. Okay. I think that's good. That flap is okay. Only thing left is maybe a little bit right here. Okay. Good. Okay, can I have a pair of cups now? Water off. This is just that anterior malleolar fold, and chorda is going to be the - the rest of chorda is going up in there. Okay. And then we want to just inspect to make sure everything looks... He - he has a pretty low tegmen. I mean, this is all tegmen here coming down, so you really can't take too much more of that. Can I have that drill one more time? But I - I just - what you want is - water on. You don't want to leave any like little divot like holes here - so spaces that you might miss. You want to be able to pack your bone pate really firmly in there. And so... Normally you want to skeletonize sigmoid - or not skeletonize it but see it well? No, you don't have to. Okay. Like I don't see sigmoid well at this point. But also, you want to create kind of a nice shallow open mastoid in case some of this bone pate doesn't take, you're not going to have some deep recess or, you know, area that becomes a nuisance for cleaning and what not. And you also want to - you know, you're polishing, and you're trying to control any bleeding that you can as well. Okay, now can I have a 7 - plain 7 suction and a bulb irrigator? So now we're going to clean up well, w - and next we're going to take some cartilage for our eardrum. And we're going to need cot - yep. Plain 7 suction - and we're going to need - Lorna, we need cotton tip applicators. Put that on - on the suction there, yeah. Are you going to take cymbal or are you going to get tragal? I'll just take some cymbal cartilage since we're behind the ear. Do you want the 11 blade and 10 blade or just the - yeah, I do. Yes, thank you. Can I have a Bovie for a second?
CHAPTER 7
Right here. Alright, double prong. Hold that. Can I have a Bovie? Now a pair of iris scissors. Got it? Okay. Yep. How did you want me to cut it? Like, did you say triangular or did you say...? Uh, rectangular - like a rectangle - small, like a - less than - like a half centimeter. Okay. Now, can I have a pair of scissors? Yeah, we're still... Okay. Now 10 blade. And smooth forceps. And now can I have the double prong - or the self-retaining retractor back? You can let go of that. Come out. So you're just getting the perichondrium off of both sides? Yep, so now I'm taking the perichondrium off this cartilage. It changes the shape of the cartilage, so I like to take it off. Then I can get a better idea of how it's going to fa - sit and bend, and then I'm going to shape it. We're going to use this cartilage to reconstruct the eardrum, and we're also going to be placing a graft today. So this will - I mean a prosthesis today. We'll be putting in a titanium total reconstruction prosthesis, and we need the cartilage to help prevent extrusion of that prosthesis. Let's have a - an 11 blade. And so now I'm going to continue to thin this cartilage. Ideally, I want the undersurface of this to be relatively flat so that it'll sit on top of the platform of the prosthesis well. Okay. Okay. And let's see how well this is going to sit. It looks pretty good. We'll probably put that like that. Okay, so that's going to be about like that. Do you have a - this - so this is going to be the total.
Can I have the - let's start with like a 4.0. Because the - even though we're rebuilding the - the canal wall in a sense, the eardrum still tends to sit a little bit lower, so I still - we still go a little bit shorter than a - what you would typically expect. Can I have a - a Rosen? Using a - using a TORP - this is a total reconstruction prosthesis. You know, it may need to go bigger. How about a 4.5? I think that's going to be about right. Okay. Hold that. There's still... I usually start smaller. Yeah, really small - this is for the station tube.
Gelfoam. Okay, more. It's good. More. You're just supporting that remnant there? I'm actually putting a little bit of packing in the station tube opening now, and we - I like to put a little bit of Gelfoam in case, you know, the patient is blowing their nose a lot or sneezing. It may prevent some - a lot of that air from coming up in here and displacing things. But I will pack a little bit more anteriorly as well. Now some Amerigel underneath this tympanic membrane remnant. One of these - one of these absorbs quicker, right? The Amerigel does. Okay. That's good for now, and then you're going to put our cartilage graft back in place here. Rosen, please. I'm going to go ahead and put my cartilage graft into position, and I'm going to allow this to come - actually cover a little bit of this jugular bulb down here. This may need to come around and rotate this a little bit. Okay. Can I now have a little bit more Amerigel? So now I'm going to put a little Amerigel underneath this cartilage in the middle ear. We're actually going to pack a little bit between the bulb and the cartilage. So this is Amerigel. It's hyaluronic acid packing. It does dissolve a little bit faster than the Gelfoam, but it helps you get a lot less adhesions with Amerigel as compared to Gelfoam packing. That's why we like to use this. Where did it - oh, nevermind. I think he's in Germany. Isn't he? I don't know. Okay, do you have that - the - that little gel film piece? Let's see. Good. Can I have some? So this is gel film, gelatin, that I'm going to lay - put a little layer over this facial nerve just as a little protection so we're not getting a lot of scarring right onto that facial nerve here even though we are going to be covering it with some bone pate. Okay - now the fascia graft. So next we're going to take our fascia graft. We're going to cut it into 2 pieces.
One is going to be a graft for the eardrum itself. And then we're also going to use a piece to cover all this bone pate, which we're going to use in the mastoid. Yeah, there's not going to be probably too much. Alright. So now, we - let's look at this. We need - about a piece to go like that. Let's have scissors. So I'm actually going to cut out a little round area where our eardrum graft will be going. So save that. That's one, and then this piece will kind of go like that. Lorna, you can save that little piece there, and then just - just keep that dry. Next, we are going to - we're going to go ahead and put our bone pate in now.
CHAPTER 8
So I need a - I need the bone pate and a dry sponge. I'm going to press all of the Floxin out now so that the bone pate is not too wet. Freer. And with a Freer, we're going to just slowly start packing the mastoid with this bone pate, filling in this mastoid cavity. And we're just going to pack this down in there. Like so. And I'm going to try to pretty much obliterate all this mastoid space. Move that over. And we're going to keep filling in all of this mastoid bone here. Cotton tip applicators now - and then I am going to try to get rid of as much moisture as I can to try to keep this relatively dry. How many do you need? I've got two. Put a 7 suction on here. That might be fine. Keep that back there so we can blot with these cotton tip applicators. Suction with a 7. Let me have it. What you don't want is if it's too wet, you worry about this bone pate getting kind of washed away as things are - are settling in here, so I try to get as much of this blood and fluid out as I can. Okay. And then we'll check. Let me have the bone pate back with a Freer? I mean with a - annulus elevator. So Freer? No, a Gimmick. And there's a little bit more we can go right down medially here - kind of lessen the space here. Okay, I'm going to need a little bit of Amerigel now. This Amerigel? Yep. I am going to put - oh. Let me have a 3 suction. I'm going to put a little bit of Amer - Amerigel. I'm going to put a little bit of Amerigel - additional Amerigel in the middle ear. and under my cartilage graft here. prior to putting our actual graft in. Can I have a 5910 for a second? Now the - let me have the big fascia graft now. And some - little bit of Floxin - alligators.
CHAPTER 9
So we're still kind of conical in shape rather than cylindrical? Yeah - yeah, the - they're still - it'll be a little bit bigger ear canal, but once the - that skin goes back down and - and things heal, you'd be surprised. It'll - it'll actually - we're going to lay that down in here. It'll narrow quite a bit. Okay. Let's have a Rosen now. and a 3 suction. We want this to come down and cover all of this area down low here. And the key here is to try and get as much of this bone pate covered as we can so that it - it does not end up getting washed away. Sometimes we have a bit much. Let me have the - some straight scissors now. Gimmick. And then the - the scissors again - the curved. And sometimes it helps to make a little cut in the back here. That will help lay this out a little bit. Okay. Can I have a basin with some irrigation in it? Gimmick. Gimmick. And then it helps sometimes to wet your graft a little bit just to kind of get this to lay down flat where you want it. And we'll use this other little piece and just cover back here. Okay. Next, I need the fascia graft - the other fascia graft. Of course you're going to bleed. Okay. Can I have now - I'm going to need a Rosen. Yeah - alligator and a Rosen. And some Floxin. Something is oozing. So now this is my underlay for my tympanic membrane. Let me have a Rosen now. And we are going to just slide that forward underneath our remnant. So that will also come up onto this posterior canal wall. And we can bring this skin back over, which is doing it's best to try and thwart us here. And - and we want to bring our other inferior flap back over like this, and we have good closure of this perforation here. Can I get another 3 suction, Lorna? This has gotten kind of clogged. And I need the prosthesis next and some small, really d - pressed out, dries of Gelfoam. Suction. Pressed out what? Gelfoam. Gimmick. Gelfoam. Like little squares, Lorna. Got it. And I get it even drier. You need me to try to do it more? Just for these few just because it's - there's some blood in here and I'm trying to - I want to try to keep it from... Okay. Another one. One more. Okay. Now titanium Alto partial - or Alto total prosthesis, sorry. This - with these prostheses you can - it's self-adjusting or you can adjust the length of it to the correct size. Let's try that again. This is the Grace Medical titanium Alto total reconstruction prosthesis. It allows you to adjust to the length you want by ratcheting the platform up and down on this stem of the prosthesis. And so we want this to be about 4.5 millimeters, which is probably about right - jeweler's forceps. And do you have a ruler? And then we're going to need the little trimmer. Ruler. And I always like to check the length and that's about - about 4.5. Okay. Trimmer. And once you've - you've adjusted to your length, you then use a little clipper to just trim off the stem. Okay. And I usually will leave a little tiny bit sticking out so it'll catch on the cartilage and prevent it from moving around too much. Now can I have a Rosen? We'll lift our flap back up here. Okay, and - we will now place our prosthesis. And that looks pretty good. Okay. And then we'll return our graft. Little more packing - just a couple more pieces of Amerigel. Smaller than that if you can, yeah. Oh, I need two pieces. Nope, that's good. Actually that might be just right. Maybe one more. Gimmick now and some irrigation - just to dip it in - and then I'm going to take Gelfoam packing. Okay. Packing. Are you done with the dipping or do you need... Yeah, I know I'm done with that. Let go. You got to open, yep. Sorry. Just - just when you - as soon as you go down, just put it open the tines - yeah, it won't fall off of there. Keep going. Keep going. You can give me a little bit - little bigger than that.
CHAPTER 10
You got Decadron, guys? Yes. Okay. And then I'm going to place some larger - there's some areas of bone pate that are still exposed back here, so we're going to just cover those with a little bit of Gelfoam. This kind of will hold it in place, but then eventually, the lining of the ear, which is covering this - the posterior ear canal wall skin will cover this, and it should heal just fine. Let's see. Marker piece - or actually, one more. What's that? For your translabs, usually put an OG tube in, correct? Yeah. Okay, no - don't - no, do you have anything bigger than that? Let's see. Look here. Yeah, just something like that. Okay. Now, can I have a pair of smooth forceps and a stitch? Smooth forceps. Okay. So now I'm going to take - this was that sort of vascular strip I created at the beginning. I'm going to fold this in to cover that skin on the posterior canal wall. And then somebody grab the ear for me and hold the ear. Just hold that ear like that. Stitch and scissors. And we're going to just kind of loosely reapproximate behind the ear, and then we'll go back and pack the remainder of the ear canal and make sure that our vascular strip that we created is lying flat against the posterior canal wall. So now, a long Crabtree. So now I want to flip my b - no, that's the short one, isn't it? Let me see the other one. Yes, sir. No, you're right. That is a long one. I'm sorry. These are different instruments. So I'm going to grab this vascular strip that we created and kind of fold it outward now. And kind of make sure that it stays unfurled. And once I have this rolled out towards me in the ear canal, we will then tuck it down. There's that little area. Okay, can I have a 3 suction now? And take this - wipe this Gelfoam. Wipe. Wipe, wipe, wipe. Wipe. Wipe. And we'll have to take some Gelfoam out because the flap is a little bit longer than - than we thought. Wipe. And we want it to lay completely flat. Wipe. Wipe. Wipe. Okay. And now the Crabtree back again. Long Crabtree. Long Crabtree. And we'll kind of... So we do have a little hole in the back of this flap, but that's okay. It - it'll - it's covered with fascia underneath. The main thing is making sure there's nothing on the edges that are curling inward, and that all looks really good. Okay, now some more Gelfoam - big pieces of Gelfoam - and a Gimmick. Gimmick. Ready? Yeah. More. And we're just successively packing Gelfoam within the canal - just filling it up. I'm going to need bacitracin at the end. I'll take that stitch back now.