Stapes Surgery

STAPEDOTOMY CONTRAINDICATIONS—-PERF OR PET, ANY DRAINAGE OR INFXN IS A DISTINCT CONTRAINDICATION—VISCID (MOBILE/FLOATING) FOOT PLATECLASER MAY BE A VIABLE OPTION HERE, PERSISTENT STAPEDIAL ARTERY, OVERHANGING FACIAL NERVE OR NEUROMA, OBLITERATIVE OTOSCLEROSIS—-OVAL OR ROUND WINDOW, HIGH JUGULAR BULB—CAN USUALLY TAMPANAD WITH GELFOAMCALOW PRESSURE SYSTEM, PATENT COCHLEAR AQUEDUCT (PERIOTIC DUCT)—CONNECTS SCALA TYMPANI OF BASAL TURN WITH POST FOSSA. MAY BE ABNL PATENT IN NEONATE, MONDINI, 2ND ARCH SYNDROME, HYDROPS—ABNL OF LOWER FACE, AND OTHER ANOMALIES—CAN PREDISPOSE TO RECURRENT MENINGITIS AND STAPES GUSHER, INFXN, PAGET=S Dz HYDROPIC (MENIER=S) HISTORY OR PATTERN SNHL DO NOT DO AS WELL, VESTIBULAR SYMPTOMS, DEPRESSED OR FLOATING FOOT PLATE, PREGNANCY, ONLY HEARING EAR, RECENT URTI, PERSONS WHO UNDERGO BAROTRAUMA (PILOTS OR DIVERS), ?CHILDREN—-SHOULD PROBABLY WAIT UNTIL THEY CAN MAKE THEIR OWN DESICION ?NEED 2 NEGATIVE FORKS CONG FOOT PLATE FIXATION—LACK AN ANNULUS AROUND THE FOOTPLATE MODIFIED ATTICOTOMY VS STAPES FLAP—INF SULCUS TO SUP—USE BELLUCI SCISSORS SUPERIORLY TO COMPLETE EXPOSURECCAN DO IT ALL WITH A FLAP KNIFE—-IF PT IS DIZZY INITIALLY IS PROBABLY THE LOCALCMUST GET IN QUICKLY AND IRRIGATE MIDDLE EAR JACOBSEN=S NERVE IX–SEE IT EVERY TIME–TYMPANIC PLEXUS OVER THE PROMONTORY EXAMINE SCUTUM +/- TRANSECT CHORDAE—-BETTER TO CUT THAN TO STRETCH TEST MOBILITY OF OSSICULAR CHAIN—–INCUS FIXATION—-REMOVE AND REPLACE WITH ESTREM TOTAL PALPATE MALLEUS HEAD—WITH MEASURING ROD LOOK FOR INCUS TIP EROSION PALPATE THE STAPES SUPRASTRUCTURE PALPATE STAPES FOOTPLATE ATTEMPT TO ELICIT R.W. REFLEX SEE THE PYRAMIDAL EMMINENCE—-CURRETE AWAY THE POST SUP MEDIAL EAC WITH THE AI@ CURRETTE OR SKEETER —SQUARE IT OFF (HOUSE) —BEGIN BE CREATING A FURROW JUST LAT TO THE BONEY ANNULUS—-CURRETTE DOWN AND OUT MEASURE FOR THE PROSTHESIS VIRTUALLY ALWAYS USE 4.25MM LENGTH! SAFEST PLACE IS POST FOOT PLATE FOR STAPEDOTOMY IF YOU CAN GET THE SKEETER IN WARN THE PATIENT AND DRILL THE POST CRUS THEN DRILL YOUR STAPEDOTOMY (HOWARD HOUSE FINGER TECHNIQUE—-WILL FEEL THE SKEETER DROP IN)—DO NOT LET IT DROP INTO THE VESTIBULE—USE A 0.7MM DIAMOND PUT A 0.6MM PISTON PROSTHESIS IN —CRIMP SEPARATE THE I-S JOINT AND ROTATE THE INCUS LATERALLY—THE JOINT IS BELOW WHERE YOU THINK IT WOULD BE—RIGHT ON THE SUPERFICIAL TENDON OF THE STAPEDIUS MUSCLE—USE THE BABY WEAPON—CAREFUL SUP AND INF MOTION—DO NOT ROCK THE OSSICLESCCAN USE THE HOUSE JOINT KNIFE FOR COMPLETION CAN USUALLY ELEVATE THE CHORDA TYMPANI OUT OF THE WAY—SEPARATE IT FROM THE MALLEUS — BETTER CUT THAN EXTENSIVELY MANIPULATED CUT THE STAPEDIUS CAN ROCK THE STAPES SUPRASTRUCTURE FREE TOWARDS THE PROMONTORY—DO IT DEFINITIVELY SO AS TO FRACTURE IT REMOVE IT AND CLOSE FOOT PLATE LOOKS BLUISH—AFTER REMOVAL LOOKS BLACK—DO NOT SUCTION PERILYMPH!C24 SUCTION WITH OUT THUMB ON THE HOLE LASER THE STAPEDIUS AND LATER THE POST CRUS OF THE STAPES—-REMOVE IT AN PERFORM A LASER STAPEDOTOMY LASER STAPEDOTOMY—LESS INVASIVE, SMALLER FENESTRA, BETTER LONG TERM CLOSURE IN HIGH FREQ? PLACE PROSTHESIS WITH A SMALL ALLIGATOR 0.6 X 4.5 MM SCHUTNECK PISTON AND WIRE PROSTHESIS USUALLY SUFFICES USE A CHISEL TO PLACE IT
CRIMP—TEST GET SOME AREOLAR TISSUE FROM THE POST AURICULAR SULCUS (CLOSE WITH 4-0 CHROMIC) COLLAGEN MICRODOTS IN ME AND EAC LOCAL CONSIDER COOLING BLAKET—FOR SURE ONLY USE 1 DOWN SHEET 25 MG IV DEMEROL AND 2.5 MG VALIUM SLOW IV PUSH (BURNS)–GIVE WHEN YOU CALL—-REPEAT JUST PRIOR TO INJECTION 2%LIDO WITH EPI INJECT SLOWLY–1-2 MM LAT TO B-C JUNCTION–POST/INF–BEVEL PARA LLEL TO BONE–INJECT UNDER PERIOSTIUM–THEN POST/SUP KEEP RELATIVELY QUIET POST OP BEDREST—-23 HR OBS HOB >30 UP TO BEDSIDE COMMODE WITH ASSISTANCE ONLY VALIUM 2-5 MG IV Q 4 PRN AND CALL HO CONSIDER ZOFRAN KEFLEX—-FOR 7 D POST OP PERCOCET CHLOROMYCETIN OTIC DROPS 4 QID—-FLOXIN OTIC DROPS BID SNEEZE WITH MOUTH OPEN NO STRAINING FOR 2-3 MONTHS NO BAROTRAUMA (FLYING/DIVING) PERIOD IF AT ALL POSSIBLE H2O PRECAUTIONS STOOL SOFTENERS IF YOU MUST TAKE A SHOWER WITH IN 3 DAYS—PLACE A COTTON BALLWITH VASELINE IN THE CONCHAL BOWL F/U IN 1 MONTH ELS WHAT EVER YOU THINK ABOUT IT—HAS STOOD THE TEST OF TIME AND IS NON-ABLATIVE—STILL KIND OF SPOOKY MAKE YOUR INCISION MORE POST FOR A FUTURE NERVE SECTION! DO A COMPLETE MASTOID—-BE AGGRESSIVE ID THE FACIAL NERVE WELL ID ALL THE CANALS—CAN BLUE LINE >EM IF YOU WANT MEASURE 10 MM POST ALONG THE LONG AXIS OF THE LATERAL CANAL MEASURE 12 MM INF FROM THE FRONT OF THE LAT CANAL STAY OUT OF THIS REGION AND YOU AVOID DAMAGE TO THE POST SCC SAC IS SUPPOSEDLY LOWER AND SIGMOID MORE ANT IN HYDROPIC PTS ELS IS DEEP AND INF TO DONALDSON=S LINE AND TRAUTMAN=S TRIANGLE ELS COMES OUT OF THE UTRICLE AND SACCULE THROUGH THE VESTIBULAR AQUEDUCT EGGSHELL ALL THE BONE POST TO THIS AND DECOMPRESS THE SIGMOID AND DURA DOWN TO IT FIND THE SAC AND DO WHAT EVER—-MAY SEE A BIT OF A RAISE ADIMPLING@ INDICATING ITS ENTRY POINT SOME SAY IT IS EASIER TO GET UNDER IT THAN INTO IT—-PROBE IT A COUPLE OF TIMES PUT SOME DEXAMETHASONE IN THE MIDDLE EAR VIA THE ANTRUM PUT SOME DEXAMETHASONE IN GELFOAM OVER THE SHUNT PUT THE PT ON VALTREX GIVE 10 OF DECADRON SEND HOME WITH A MEDROL DOSE PACK OR 60 – 80 MG PRED QD FOR 10-14 DAYSCPROBABLY OUGHT TO TAPER THAT DOSE OUT SHUNTING TO THE SAS IS COUNTER-INTUITIVE AS THE PRESSURE IN THE SAS EXCEEDS THAT OF THE ENDOLYMPHATIC SPACE COMPLICATIONS DYSGEUSIA AND TRANSIENT VERTIGO ARE ACCEPTABLE EARLY POST OP SEQUELAE FACIAL PARALYSIS—WAIT 2-4 HOURS FOR LOCAL TO WEAR OFF REVEIW THE CASE—-CALL A COLLEGUE—-TALK THE PATEINT AND FAMILY—MOST COMMON SURGERY IS CANALPLASTY (EXOSTOSIS) AND MOST COMMON SITE IN CHRONIC EAR SURGERY IS SECOND GENU PLF—GEL FOAM WIRE LOOP PROSTHESIS—-WIRE FAT PROSTHESIS HAVE A HIGH INCIDENCE PROSTHETIC COMPLICATIONS–TOO LONG—TRANSIENT VERTIGO INCUS Fx OR DISLOCATION LOOSE WIRE—BROKEN SPEAKER HEARING DELAYED SNHL OR VESTIBULAR Sx INCUS NECROSIS—ABRUPT 50-60 dB CHL OCCURRING CLASSICALLY AT ABOUT 6 MONTHS REPAIRATIVE GRANULOMA (1-2%)—-1-6 WEEKS POST OP–?ETIOLOGY?CPOWEDER FROM GLOVES, BAD BATCH OF GELFOAM, CLOTH FIBERS, ECTY–GET A VERY SIG MIXED HL WITH POOR SDS OUT OF PROPORTION WITH THE PTA HL–MORE COMMON WITH STAPEDECTOMY VS STAPEDOTOMY

More recently I have been using a 4 mm bucket handle prosthesis on a layer of tragal perichondrium.  Or a 4.25 x 6 mm smart piston prosthesis.  Either one is giving me good results.

THICKENED TM, DEEP RED HUGHE HIGH IN THE POST SUP QUADRANT OF THE TM—-GT—MUSTY GO FOR IMMEDIATE SURGERY—-REMOVE GRANULOMA, CHANGE PROSTHESIS, GIVE STEROIDS FLOATING FOOT PLATE—CAN USE LASER, ABORT OR PLACE PROSTHESIS ON TOP SUBMERGED FOOTPLATE—LEAVE IT PERFORATED TM—–GRAFT IT OTITIS MEDIA—-CAN BE DANGEROUS NO IMPROVEMENT—AFTER 3 MONTHS CONSIDER RE-EXPLORATION—-THERE IS OFTEN A VARIABLE PERIOD OF TIME WHERE THE BONE SCORE IS MUCH WORSE THAN PREOP—–THE CONDITION/STATUS OF THE MIDDLE EAR CAN GREATLY AFFECT YOUR BONE SCORE—?MECHANISM?

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