EAR SURGERY—-DANIEL TODD, MD ALWAYS FIND OUT PREOP AND DOCUMENT POST OP: STATUS OF EACH OF THE OSSICLES STATUS OF THE FACIAL NERVE (DEHISSENCE) STATUS OF THE SCUTUM AUDIOGRAM STATUS (WITHIN 1 MONTH) EXAMINE BOTH EARS PREOP COUNSEL AND CONSENT PTS FOR FACIAL NERVE INJURY, ALTERED TASTE, VESTIBULOPATHY, TINNITUS, EAR NUMBNESS, BLEEDING, INFXN, AND DISTORTION OF THE EAR IMAGING LIKE WHEN TO OPERATE—NO CONSENSUS ON WHEN TO IMAGE GET CT SCAN FOR CHOLESTEATOMA IF : REVISION CASE, COMPLICATED CASE, ONLY HEARING EAR, LETIGINOUS PT OR Hx OR PE SUGGESTING PLF—-MANY GET CT SCAN ROUTINELY TO ASSES MASTOID AERATION OR TO PROTECT SELF FROM LAW SUIT 5 BONES IN SKULL DEV. VIA ENDOCHONDRIAL OSSIFICATION–POEMS(PETROUS, OCCIPITAL, ETHMOID, MASTOID, SPHENOID THE HALLMARK OF T-BONE ANATOMY IS VARIATION ASSESS THE SCUTUM, AERATION, AND THE COURSE OF THE FACIAL NERVE EROSION OF THE CORTICAL PLATE OVERLYING THE SIGMOID SINUS HELPS DIFFERENTIATE COALESCENT FORM NON-COALESCENT MASTOIDITIS EXT EAR LANDMARKS: ISTHMUS = NARROWEST PORTION OF THE EAC—ANGLES ANT/INF IT IS WHERE TO INJECT–IT IS WHERE THE GLANDULAR AND HAIR BEARING SKIN CHANGES INJECT SLOWLY–1-2 MM LAT TO B-C JUNCTION–POST/INF–BEVEL PARALLEL TO BONE–INJECT UNDER PERIOSTEUM–THEN POST/SUP—4 QUADRANT INJ VASCULAR STRIP = AREA OF THICKENED POST CANAL WALL SOFT TISSUE CAN BE DEFINED BY INJECTION AS IT IS BETWEEN THE TYMPANOSQUAMOUS (SUP) AND TYMPANOMASTOID (POST/INF) SUTURE LINES—-JOIN WITH THE ENDS OF THE ANNULUS AT THE NOTCH OF RIVINUS LIMBUS = ANNULUS IN SULCUS FISSURES OF SANTORINI—–A POTENTIAL SPACE RESULTING FROM FIBROVASCULAR DEFECTS IN THE CARTILAGE OF THE EAC—FACILITATE THE SPREAD OF INFXN OR TUMOR PARS TENSA HAS LAMINA PROPRIA = TRILAMINAR–DOES NOT REGENERATE AFTER A PERF—DIMERIC REPLACEMENT-APPEARS TRANSLUCENT (OFTEN ERRONOUSLY REFERRED TO AS MONOMERIC) CENTER IS MOST LIKELY TO PERF DUE TO CONFIGURATION OF BLOOD SUPPLY STRIA VASCULARIS= AN INNER EAR STRUCTURE (ENDOLYPH PRODUCTION IN COCHLEAR DUCT) AND A VASCULAR ARCADE COARSING DOWN THE LONG PROCESS OF THE MALLEUS MYRINGOSCLEROSIS = HYALINIZATION OF THE LAMINA PROPRIA (WHITE PLAQUES)—A SUBSET OF TYMPANOSCLEROSIS—-CAN HAPPEN ANYWHERE IN THE MIDDLE EAR ENDAURAL (LEMPERT) APPROACH [ENDAURAL INCISION OF LEMPERT—INCISE SUP UP THE TYMPANOSQUAMOUS SUTURE LINE—BRING OUT SUPERIORLY THROUGH THE INCISURA—-MAY CONNECT AROUND SUP EAR AND BACK TO GO POST AURICULAR—–MAY TAKE CARTILAGE AND PERICHONDRIUM FROM RIGHT THERE]—-POPULAR IN EUROPE—CAN USUALLY GET AWAY WITH IT BECAUSE CHRONIC EARS HAVE SUCH SMALL SCLEROTIC MASTOIDS TRANSCANAL APPROACH (BEST TOLERATED) WORKS WELL FOR TM PERFS AND EXPOSURE POST TO THE MALLEUS AS FAR AS CHRONIC EAR SURGERY–THE MOST YOU CAN DO IS AN ATTICOTOMY THROUGH THIS APPROACH STEPS BALANCE WILDE MICROSCOPE TEACHING SCOPE OUT—–CAMERA IN TURN TABLE SO EAR TOWARDS ANESTHESIA EYE PIECES DOWN AT -3 DONUT—ONLY FOR HEAD STABILIZATION FOR DRILLING (MASTIOD)OR GOING POST AURICULAR—OTHERWISE DO NOTHING (NO PILLOW) SHAVE IOWA HAT–MASTISOL–BLENDERM TAPE–MAKE WATER TIGHT STERISTRIP ON EYE OR TARSORRHAPHY STITCH BETADINE SCRUB–NO BETADINE IN EAC IF PERF (OTOTOXIC)? DRY SKIN HEAD SHEET TOWELS–LEAVING FACE EXPOSED DOWN SHEET NIMS: 2 RED LIPS (AT COMMISSURE), 1 BLUE EYE (SURROUND EYEBROW), GREEN-GLABELLA-GROUND–JUST UNDER THE SKIN STATUS CHECK–BOTH < 1, EVENT CAPTURE OFF, CAPTURE AT 50 BIODRAPE(VI-DRAPE) SCHMOO BAG FOR DRILLING—STAPLE IT ON POST AURICULAR APPROACH—-BEST FOR THE OCCASIONAL OPERATOR BEST FOR EXPOSURE FOR ANY WORK ON TM ANT TO THE MALLEUS MORE DIFFICULT TO GET INTO THE MIDDLE EAR—USE MORE ANGLED END OF THE FLAP KNIFE STEPS SHAVE 1 INCH POST AURICULARLY PUT ON FACIAL NERVE MONITOR—-STICK ON WITH BLENDERM TAPE SQUARE OUT EAR WITH 10-10’S (CUT IN HALF) PREP DRAPE—NO NEED TO SEE ANYTHING EXCEPT THE EAR—PROBABLY STUPID TO NOT HAVE A VIEW OF THE FACE TURN UP THE FACIAL NERVE MONITOR INJECT POST AND INTRA AURICULAR—TRY TO BALLOON UP THE VASCULAR STRIP MAKE YOUR VASCULAR STRIP INCISIONS—-CURVED BEAVER CUT FROM 12 TO 8 JUST LATERAL TO THE BONEY ANNULUS
CUT OUT FROM HERE TO THE B-C JUNCTION—FOLLOW INFERIORLY WITH YOUR CURVED BEAVER DOWN TO 6 O=CLOCK FOR TYMPANOPLASTY GO POST AURICULARLY TO HARVEST GRAFT—-MAKE IT BIG—USE BACK OF KNIFE AND A FREER FOOLS FASCIA MOVES—USE LOCAL TO BALLOON UP TRUE TEMPORALIS FASCIA FOR CARTILAGE GRAFT T-PLASTY USE TRAGUS CAN USE TRAGUS PERICHONDRIUM (ON EAC SIDE)—–ANT SIDE IS BARE— PUT PERICHONDRIUM TOWARDS THE TM IN UNDERLAY GRAFTS DO NOT HESITATE TO USE MICROSCOPE INCISION ON CANAL SIDE OF TRAGUS–CUT THROUGH CARTILAGE WITH 15 BLADE—LEAVING THE LATERAL TRAGUS INTACT SPREAD WITH TENOTOMY SCISSORS ON EAC SIDE SHARPLY DISSECT (CUT) ANT MUSCLE ATTACHED TO PERICHONDRIUM RAISE FLAP—#3 SUCKER IN LEFT HAND START INCISION AT ABOUT 6 – 8 O=CLOCK—FOR A POST PERF (STAY ANT TO THE INF INCISURA/CROTCH) OTHERWISE START FLAP INFERIORLY AT THE ANT BORDER OF THE PERF—START AT ANNULUS LEAVE ANNULUS AT ALMOST 90 DEGREES—CURVE UP GENTLY TO NEAR THE BC JUNCTION CUT ALONG THE BC JUNCTION AROUND POSTERIORLY TO ABOUT 12 O=CLOCK—ERROR ON THE SIDE OF A LONG FLAP CAN USE FLAP KNIFE ENTIRE TIME FLAP KNIFE—-MODIFIED ATTICOTOMY FLAP—–CONSIDER USING BEAVER BLADE OR BELLUCCI SCISSORS FOR SUP THICK PORTION OF FLAP CUT FLAP WITH MORE ANGLED END RAISE FLAP WITH LESS ANGLED END USE BIGGER SPECULUM AND LESS MAGNIFICATION AT FIRST—THEN MOVE IN RAISE FLAP–CURETTE SCUTUM TO VIEW PYRAMIDAL EMINENCE USUALLY CAN PUSH CHORDAE OUT OF THE WAY USE EYE CURETTE OR SKEETER DRILL SOME USE A SPECULUM HOLDER CAN ENLARGE THE EAC WITH A SUP INCISION AND A NASAL SPECULUM—-CAN ACTUALLY DO A SIMPLE OR BONDY MASTOIDECTOMY OR ATTICOTOMY THROUGH A LEMPERT ENDAURAL INCISION COLLAGEN MICRODOTS IN ME AND EAC CLOSE TRAGUS WITH 6-0 MILD CHROMIC–INTERRUPTED CLOSE POST AURICULAR WITH 4-0 MILD CHROMIC POST OP PACKING LEFT IN PLACE FOR 2-4 WEEKS AVOID HEAVY LIFTING AND NOSE BLOWING (SNEEZE WITH MOUTH OPEN) FOR 3 WEEKS STERILE MASTOID DSG (GLASSCOCK EAR CUP) OVERNIGHT–NOT NEEDED UNLESS YOU GO POST AURICULARLY START DROPS (CORTISPORIN) AND PULL POST AURICULAR RUBBER BAND POD #1—-ONLY NEED CHLOROMYCETIN OR CIPRO/FLOXIN DROPS IF ENTERED THE INNER EAR PULL POPE EAR WICK OF PACKING AT ONE WEEK—PT CAN DO THIS AT HOME ANTIBIOTICS–NOT NEEDED FOR ROUTINE T-PLASTY (DIFFICULT TO PROVE THEY ARE EVER INDICATED IN EAR SURGERY) F/U IN 4 WEEKS FOR EVAL AND CLEANING OF EAC—-CAN DO PNEUMATIC OTOSCOPY AT THIS TIME—REMOVE ALL RESTRICTIONS AND RESUME NL ACTIVITY—THEN F/U IN 6-8 WEEKS WITH AN AUDIO (MIDDLE EAR GEL FOAM SHOULD BE GONE)–-OINTMENT NEVER LEAVES TYMPANOPLASTY TM ATELALECTASIS GRADE I = SLIGHT RETRACTION OF TM OVER ITS ANNULAR FOLD GRADE II = TM TOUCHES OSSICULAR CHAIN (MISP) GRADE III = TM TOUCHES PROMONTORIUM GRADE IV = TM IS ADHERENT TO PROMONTORIUM—ADHESIVE OTITIS MEDIA STAGES OF TM RETRACTION (RP)–PER JACOB SADE STAGE I = SLIGHT DIMPLE (MICROMETULA) STAGE II = SHRAPNELL MEMBRANE IS RETRACTED MAXIMALLY (OVER THE NECK OF THE MALLEUS) STAGE III = STAGE II + SOME SCUTAL EROSION STAGE IV = DEEP (ATTIC RETRACTION POCKET) USUALLY WITH ACCUMULATED KERATIN CANNOT BE REACHED BY SUCTION RP=S HAVE DIFFERENT CELLULAR ACTIVITY FROM SURROUNDING TM—–TRY TO RESECT THE RP IF POSSIBLE RP=S ARE NOT SECONDARY TO PETS—BUT RATHER THE CHRONIC INFECTION AND INFLAMMATION (PROTEOLYTIC ENZYMES) CHILDREN GET AQUIRED CHOLESTEATOMAS FROM POST SUP PARS TENSA RP=S WHILD ADULTS GET ATTICK RP=S AND CHOLESTEAMA THERE IS NO CONSENSUS ON WHEN TO OPERATE-—-THERE IS GOOD EVIDENCE THAT YOU CAN PREVENT CHOLESEATOMA BY OPERATING EARLY—–BUT IF YOU HAVE A COMPLICATION YOU LOOK LIKE AN IDIOT—-PROBABLY BEST NOT TO FIX IT IF IT AINT BROKE YET!!! (THERE IS ALSO EVIDENCE THAT EXPECTANT AND CONSERVATIVE MANAGEMENT MAY GET THEM BY —EVEN FOR THE LONG HAUL!)—BE CONSERVATIVE ALAKE A FACIAL NEUROMA OR GENICULATE OSSEOUS HEMANGIOMA@ ONE OF THE OTOLOGIST=S DILEMMAS OPERATE FOR THEM —-NOT ON THEM
AERATION OF THE MIDDLE EAR IS KEY LONG TERM PROGNOSTIC FACTOR—–@AS THE ET GOES, SO GOES THE EAR@—MAY ALSO BE DEPENDENT ON FORMATION OF MIDDLE EAR ADHESIONS BIGGEST IMPEDEMENT TO HEALING A PERF OR A T-PLASTY IS INFXN! FAT GRAFT MYRINGOPLASTY TYPE I TYMPANOPLASTY = MYRINGOPLASTY = RECONSTRUCTION OF A NEW TM WITH INTACT NL OSSICLES (MAY JUST DO PAPER PATCH, LYSIS OF ADHESIONS AND PARTIAL MYRINGECTOMY, FASCIA GRAFT OR MAY DO CARTILAGE GRAFT T-PLASTY–PRIMARILY FOR LARGER POST SUP PERFS)— AERATION OF THE MIDDLE EAR IS CRITICLE IN DECISION MAKING REGARDING THE NEED FOR A CARTILAGE GRAFT—IF YOU ARE GOING POST AURICULAR AND YOU NEED CARTILAGE USE CONCHAL BOWL—OTHERWISE TRAGUS TYPE I TYMPANOPLASTY UNDER OR OVERLAY BASED ON REFERENCE TO FIBROUS LAYER OF TM UNDERLAY =LESS DIFFICULT AND LESS HEALING PROBLEMS ERR ON THE SIDE OF DOING A POST AURICULAR OVERLAY ERR ON THE SIDE OF STAGING—PLACEMENT OF A THICK PEICE OF SILASTIC TO PREVENT ADHESIONS OVERLAY(LAT)(THE LOS ANGELOS TECHNIQUE = THE SHEEHY TECHNIQUE)DO BY A RETROAURICULAR APPROACH, DRILL DOWN THE ANT CANAL WALL TO THE TMJ, CAN PROBABLY DO UNDER MORE ADVERSE CONDITIONS=MORE DIFFICULT, CAN LATERALIZE–BLUNTED ANT CANAL ANGLE (BLIND SAC) BUT……BETTER TAKE RATE AND BETTER EXPOSURE (CLAMP = COMPLICATIONS) CANAL STENOSIS, LATERALIZATION, ANT. BLUNTING, MURAL CHOLESTEATOMA, PERFORATION IF YOU GET INTO THE TMJ (GLENOID FOSSA) YOU WILL SEE AN OUT POUCHING OF FAT—JUST BOVIE IT LIGHTLY AND MOVE ON POST AURICULAR INCISION—-MAKE THE CUTS ANT ENOUGH—VASCULAR STRIP INCISION ELEVATE THE EAR AND VASCULAR STRIP CUT THE ANT B-C JUNCTION—-ELEVAT THE REMAINING CANAL SKIN DO CANALPLASTY—“MICKEY MOUSE EARS” TO VIEW THE ENTIRE ANNULUS—-BE CAREFUL INFERIORLY AND POSTERIORLY—DRILL WITH A DIAMOND PARALLEL TO THE FACIAL NERVE—THE NUMBER ONE SURGERY CAUSING INJURY TO THE FACIAL IS CANALPLASTY FOR EXOSTOSIS. REMOVE ALL THE CANAL AND TM EPITHELIUM EXAMINE THE MIDDLE EAR AND OSSICLES—-GELFILM ON THE PROMONTORY—-GELFOAM IN THE MIDDLE EAR—MAY USE MEROGEL SOME—–EASIER TO HANDLE—ACTS LIKE COTTON—-CAN SUCTION ON IT APPLY GRAFT WITH CUT FOR THE LONG PROCESS OF THE MALLEUS—-DO WRAP AROUND—GIMMICK AND AN EAR CURRETTE WORK WELL—LAY ON ENTIRE ANNULUS- PIE CRUST SLITS—REAPPLY CANAL SKIN—APPLY IT DEEP—-GETLY ELVATE IT OUT PACK DOWN WITH MEROGEL—CAN SUCTION ON IT REPLACE VASCULAR STRIP—-PACK CANAL WITH GELFOAM LIGHTLY DIPPED IN ANTIBIOTIC DROPS COTTON BALL IN THE CONCHAL BOWL MASTOID EAR CUP OVER NIGHT—-TAKE IT HOME TO SLEEP WITH FOR FIRST WEEK SHOWER WITH COTTON BALL/VASELINE NO OTHER CARES—FOLLOW UP IN 7-10 DAYS FOR A RECHECK—GENTLY CLEAN OUT LAT CANAL AND PROBABLY START DROPS SOON AFTER—ALSO REMOVE ANY POST AURICULAR STICHES F/U AGAIN IN ABOUT 1 MONTH TYPE II TYMPANOPLASTY =FOR THE RARE CASE OF ISOLATED MALLEOLAR EROSION OR DAMAGE— RECONSTRUCTION OF TM OVER INCUS OR REMAINS OF MALLEUS (FOR PERF WITH MALLEOLAR EROSION) TYPE III = FOR INCUS EROSION OR DAMAGE—–TM OVER A FREELY MOBILE STAPES (ALSO SONIC SHIELD FOR ROUND WINDOW) TYPE III = TM ON STAPES THE FOLLOWING ARE BETTER TERMED OSSICULOPLASTIES TYPE III IG = INCUS GRAFT TYPE III IGM = INCUS GRAFT TO MALLEUS TYPE III MR = MALLEUS REPOSITIONED TYPE III MG = MALLEUS GRAFT TYPE III BG = BONE GRAFT TYPE III SS MS = STAINLESS STEEL MALLEUS TO STAPES TYPE IV = FOR STAPES SUPERSTRUCTURE DAMAGE-—TM OVER MOBILE STAPES FOOTPLATE (STILL AIR POCKET OVER RW) ALL TYPE III AND IV PRONE TO COLLAPSE AND NULLIFY ANY HEARING IMPROVEMENT TYPE V = FOR FIXED FOOTPLATE TYPE Va = FENESTRATION TYPE Vb = STAPEDECTOMY TORP AND PORP BOTH TOUCH ON THE TM (EACH CONSIST OF A CAP AND A SHAFT) HA IS BIOCOMPATIBLE AND TRANSMITS SOUND WELL OTHER PROSTHESIS= ARE NAMED BY THE OSSICLES THEY REPLACE: INCUS-STAPES PROSTHESIS, INCUS -REPLACEMENT PROSTHESIS—NEW TITANIUM PROSTHETICS SEEM TO DO VERY WELL (KURZ) SUCCESS? — <15 DB WITH OSSICULAR REPLACEMENT, <20 DB WITH PORPS, <25DB WITH TORPS NO SIG USE FOR ABX MIDDLE EAR DEFINITIONS: CONTROVERSIAL—THE CLASSIFICATION FOR CHRONIC EAR SURGERY INVOLVING MASTOIDECTOMY TYMPANOPLASTY WITH MASTOIDECTOMY OPEN CAVITY TECHNIQUE (CWD) OBLITERATION TECHNIQUE (CWD) INTACT CANAL WALL PROCEDURE (CWU) RADICAL MASTOIDECTOMY MODIFIED RADICAL MASTOIDECTOMY (BONDY)—TM AND MIDDLE EAR LEFT INTACY—MASTOID AND EPITYMPANUM EXTERIORIZED MASTOID OBLITERATION TECHNIQUE OTHER TERMINOLOGY ANTROSTOMY SIMPLE MASTOIDECTOMY–@NOTHING SIMPLE ABOUT IT MISTER@ (CORTICAL MASTOIDECTOMY OF SCHWARTZE 1873) = GAIN ACCESS TO THE ANTRUM (ANTROSTOMY), ATTIC, LABYRINTH, AND ELS—-DO NOT GAIN ACCESS TO THE MIDDLE EAR—THE CANAL WALL IS LEFT UP CLOSED OR CWU MASTOIDECTOMY(70%)—MOST PREFER TO JUST CALL A CWU MASTOIDECTOMY AS THE MODIFIED PART IS IMPLIED = A SIMPLE MASTOIDECTOMY WITH ACCESS TO THE MIDDLE EAR—-(BETTER CONTOUR, BETTER FUNCTION, LESS MAINTANCE)—-SHOULD INCLUDE A RELOOK IN 6-18 MONTHS—-SHOULD FOLLOW EVERY YEAR FOR UP TO 10 YEARS? FACIAL RECESS = AN AERATED EXTENSION OF THE POST-MESOTYMPANUM—- MEDIAL TO THE TYMPANIC ANNULUS/CHORDA TYMPANI AND ANTERO-LATERAL TO THE FALLOPIAN CANAL(FACIAL NERVE) AND INF TO THE FOSSA INCUDUS (BUTTRESS) MODIFIED FACIAL RECESS—REMOVE BUTTRESS TO CONNECT FOSSA INCUDIS AND FACIAL RECESS EXTENDED FACIAL RECESS—SACRIFICE THE CHORDAE TO ACCESS THE HYPOTYMPANUM BETWEEN THE ANNULAR LIGAMENT AND THE FACIAL NERVE OPEN OR CWD
CWD MRM(30%) [MRM = GAIN ACCESS TO THE MIDDLE EAR BUT LEAVE AN INTACT MIDDLE EAR CLEFT]= A SHALLOW MIDDLE EAR CLEFT AND A PERMANENT MASTOID BOWL—SHOULD COMBINE WITH A MEATOPLASTY TO FACILITATE CLEANING AND MAINTAINANCE–OFTEN NEEDED TO GAIN EXPOSURE TO THE MESOTYMPANUM (SINUS TYMPANI)—AS THIS IS THE PRIMARY SITE FOR RESIDUAL DISEASE—-MUST DO A THOUROUGH SAUCERIZATION OF MASTOID WITH ALL CWD TECHNIQUES (NOT WITH CWU)—-(FOR NON-COMPLIANT, DIFFICULT DZ, RECURRENT DZ, LATERAL CANAL FISTULA, VERY POOR HEALTH, ALREADY HAVE A CONTRALATERAL CAVITY, ONLY HEARING EAR?–REQUIRES A LIFE OF MASTOID BOWL CARE)—NEED Q 6 MONTH CLEANING MINIMALLY BONDY MRM = A SIMPLE MASOIDECTOMY WITH CWD–TO LEVEL OF ANNULUS—EXTERIORIZE ATTIC CHOLESTEATOMA AND LEAVE THE MEDIAL MATRIX AS THE SKIN LINING OF THE MASTOID BOWL—REALLY LEAVE MIDDLE EAR UNDISTURBED–INDICATION LIMITED TO ATTIC CHOLESTEATOMA NO MIDDLE EAR DISEASE—END UP WITH A MUCH HIGHER AFACIAL RIDGE@ REGION—MAY BE MORE DIFFICULT TO CLEAN BUT MAINTAIN THE DEPTH AND ACOUSTIC RESONANCE OF THE MIDDLE EAR FOR BETTER HEARING—PROBABLY A GOOD OPTION IN OLDER PTS WITH ATTIC CHOLESTEATOMA AND CHL—-CAN LEAVE OR REBUILD THE HEARING WITH OUT NEEDING A RETURN TO THE OR RADIAL MASTOIDECTOMY—NO MIDDLE EAR CLEFT LEFT (PACK ETT), DRILL OUT THE HYPOTYMPANUM, REMOVE ALL THE OSSICLES—-MAY FLAP MUSCLE INTO THE MIDDLE EAR (RAMBO PROCEDURE) TYMPANOMASTIODECTOMY–A COMBINATION TERM—PROBABLY BEST AVOIDED INCUS = LARGEST OSSICLE STAPES = SMALLEST BONE IN BODY: STAPEDIUS = SMALLEST MUSCLE IN BODY BELLY OF THE STAPEDIUS CAN LOOK LIKE THE FN (SO CAN THE TENDON OF THE TENSOR TYMPANI)—SEE IT DEEP (MEDIAL TO THE SECOND GENU PERSISTENT STAPEDIAL ARTERY = A PROBLEM DURING STAPEDECTOMY MALLEUS HAS NO BODY INCUS HAS NO HEAD (THE BODY CAN BE FASHIONED INTO AN INTERPOSITION GRAFT) STAPES HAS NO NECK (THE POST CRUS IS MUCH THICKER THAN THE ANT) INCUS—LOOKS LIKE ICE CREAM CONE ON CT SCAN—ICE CREAM PART IS INCUS BODY—-1ST ARCH DERIVATIVE LENTICULAR PROCESS OF INCUS MOST SUSCEPTIBLE TO AVN (MAX CHL= 60 DB– 6 MONTHS AFTER A STAPES) 33-50%—FN DEHISCENCE AT O.W. JUGULAR BULB R>L MALLEUS ADHERED TO TM AT UMBO AND SHORT PROCESS—OTHERWISE A SLIGHT FIBROUS CONNECTION APLICAE MALLEARIS@ WHICH IS EASILY DISSECTED OFF–MUST DO THIS TO PLACE AN ESTREM PROSTHESIS STRIAE VASCULARIS (ALSO IN COCHLEAR DUCT) IS CASCADE OF BV=S RUNNING DOWN THE LONG PROCESS(MANUBRIUM) OF THE MALLEUS FACIAL SINUS (RECESS) CELLS = PRIMARY SITE FOR RESIDUAL Dz—-MAY NEED A CWD PROCEDURE HERE SINUS TYMPANI (DESCRIBED BY MECKEL=1820—MECKELS GANGLION = SP, MECKELS CAVE = TRIGEMINAL)—-A DIFFICULT SITE TO REMOVE CHOLESTEATOMA FROM SAFELY—-MAY NEED A CWD PROCEDURE HERE COCHLEARIFORM PROCESS(ROSTRUM) ASPOON SHAPED@—THE ORIGIN OF THE TENDINOUS ATTACHMENT FOR THE TENSOR TYMPANI—CN V—RUNS PARRALLEL AND SUP TO THE ETT 7 UP RULE= THE SEVENTH NERVE(NEAR THE GENICULATE) IS ALWAYS? SUP TO CHOCLEARIFORM PROCESS—-THE GENICULATE GANGLION IS RIGHT THERE! COG = A HOUSE TERM—IS THE BONEY PROMINENCE IN THE EPITYMPANUM WHICH ORIGINATES THE SUP OSSICULAR LIGAMENTOUS ATTACHMENT AND SEPARATES THE ANT AND POST EPITYMPANUM—-MAY WANT TO DRILL THIS FLAT (TEGMEN TYMPANI) TO ACCESS THE ANT EPI TYMPANUM AND TO KEEP IT AERATED—SEE WHAT YOU ARE DOING —THE FACIAL TURNS UP HERE RIGHT ANGLE BALL TIP SEEKER=LILLY HOOK CHORDAE RUNS BETWEEN THE MALLEUS AND INCUS—-A CRITICAL ANATOMIC POINT STAPEDIUS ORIGINATES ON PYRAMIDAL PROCESS–SHOULD VISUALIZE THIS IN A STAPEDECTOMY- END OF THE SHORT PROCESS OF THE INCUS BISSECTS THE LAT SCC—-THE LIGAMENT OF THE SHORT PROCESS ATTACHES TO THE BUTTRESS THE BUTTRESS IS REALLY JUST AN ARTIFICIAL BONEY CONNECTION WHICH SEPARATES THE FACIAL RECESS FROM THE FOSSA INCUDIS—LIGAMENT TO THE INCUS ORIGINATES HERE—STUDIES DO NOT DEMONSTRATE ANY PROBLEMS (CHL) TAKING DOWN THE BUTRESS THE FOSSA INCUSUS IS A POST EXTENSION OF THE EPITYMPANUM WHICH QUICKLY BECOMES CONTIGUOUS WITH THE ANTRUM—POINTS TO THE FACIAL NERVE (FACIAL RECESS) ALWAYS SEE JACOBSON=S NERVE RUNNING IN A GROOVE ON THE COCHLEAR PROMONTORY THE PROMONTORY IS THE BONE OVERLYING THE BASAL TURN OF THE COCHLEA–EXTENDS POST AS BONEY LANDMARKS–THE SUBICULUM AND PONTICULUS COCHLEAR PROMONTORY—–OVER IT IS THE OW, UNDER IT IS THE RW, POSTERIOR TO IT IS THE SINUS TYMPANI——THE PONTICULUS (SUP) SEPARATES THE OW FROM THE SUP SINUS TYMPANI—-THE SUBICULUM (INF) SEPARATES THE INF SINUS TYMPANI FROM THE RW LENTICULAR PROCESS OF INCUS = MOST SUSCEPTIBLE TO AVN —FLARES OUT LIKE A BELL PRIOR TO I-S JOINT—WHEN SEPARATING THE I-S JOINT ALWAY GO MORE TOWARDS THE STAPES THAN YOU THINK—–USE A STRAIGHT PICK THROUGH THE FACIAL RECESS AND A BABY WEAPON TRANS CANAL USE THE CURRETTES A LOT—VERY SAFE—-GOOD CONTROL—–VERY DIFFICULT TO CURRETE THROUGH THE OTIC CAPSULE ALWAYS TAKE THE TM UP TO THE LAT PROCESS OF THE MALLEUS—SEE IT!—DO NOT HESITATE TO NIP OFF THE MALLEUS HEAD FOR ACCESS THE FACIAL NERVE IS DIVIDED INTO 3 REGIONS BY T-BONE(PRE,INTRA,POST) PRE=INTRACRANIAL SEGMENT=23-24MM INTRA-TEMPORAL BONE PORTION MEATAL SEGMENT 9MM IAC TO MEATAL FORAMEN
LABYRINTHIAN SEGMENT= PREGENICULATE SEGMENT OF PERIGENICULATE REGION 3-6MM (THE NARROWEST) PRIMARY REGION FOR BELLS TO LIGHT UP ON A GAD SCAN TYMPANIC SEGMENT=POSTGENICULATE SEGMENT OF PERIGENICULATE REGION ?IS PRIMARY REGION FOR T-BONE FX TO DISRUPT NERVE 8-11MM MASTIOD(VERTICLE) SEGMENT (SECOND GENU IS THE DANGER AREA) POST=EXTRATEMPORAL SEGMENT PRE-PES POST-PES STEPS VASCULAR STRIP INCISION POST AURICULAR APPROACH (INCISION OF WILDE) 8-10 MM FROM POST AURICULAR CREASE (PUSH EAR DOWN–MAKE INCISION AT HELICAL CREASE)—-BRING INF PORTION OF THE INCISION OUT POST IN PEDS TO PREVENT FACIAL NERVE INJURY—-BE CAREFUL AS FACIAL NERVE MAY ACTUALLY EXIT THE MASTOID LATERALLY—BE SURE TO GO ANTERIOR ENOUGH TO EASILY FOLD THE EAR FOOL=S FASCIA–SUPERFICIAL TO TEMPORALIS FASCIA–MOVES WITH MANIPULATION OF OVERLYING TISSUES(DAVIS USES IT)–INJECT 1% WITH UNDER IT TO BALLOON IT UP TEMPORALIS FASCIA DOES NOT MOVE—-PRESENT ONLY OVER THE TEMPORAL LINE (HIGHER IN PEDS)—-PLACE 2 DOUBLE PRONGED SKIN HOOKS IN THE INCISION AND PULL THE SKIN EDGES UP AND MOVE THEM PERIODICALLY USE THE HANDLE OF YOUR SCALPEL TO HELP DEVELOPE THE PLANE PUT YOUR FINGER IN THE EAC AND POINT YOUR KNIFE TOWARD IT IN THIS PLANE AND COMPLETE YOUR INCISION THE POSTERIOR MUCOPERIOSTEAL (MINI-PALVA) FLAP(A BIT MORE THAN 1 FINGERS WIDTH) VS T-FLAP (CAN DO WITH BOVIE) MINI-PALVA MAY HELPS OBLITERATE MASTOID CAVITY (NOW CAN USE H.A. CEMENT)—-MAKE A LARGE PALVA FLAP—USE AN L FLAP FOR REVISIONS TO AVOID CUTTING INTO AN ADJACENT SIGMOID SINUS—MAY USE A KNIFE INSTEAD OF A BOVIE USE LEMPERT OR JOSEPH ELEVATOR—-TO RAISE FLAP ALWAYS RECONSTRUCT FLAP TO KEEP POST EAC PULLED POST FOR PATENCY OF THE EAC DEFINE BONEY LANDMARKS EVERY TIME: MACEWEN=S TRIANGLE = TEMPORAL LINE, POST EAC, AND LINE BETWEEN THE TWO—CONTAINS SUPRAMEATAL SPINE OF HENLE AND AREA CRIBROSA—IT IS WHERE TO START MASTOID TIP, TEMPORAL LINE(HIGHER IN CHILDREN–TENDS TO SWOOP OFF SUP AS YOU MOVE POST), SUPRAMEATAL SPINE OF HENLE, CRIBRIFORM AREA—-WHERE SUBPERIOSTEAL ABCESS FORMATION STARTS MAY COME ACROSS SIG BLEEDING VIA THE MASTIOD EMMISSARY VEIN (MASTIOD FORAMEN) BE SURE TO DEFINE YOUR MASTOID TIP WITH THE LEMPERT ELEVATOR—-THE SMF IS QUITE MEDIAL TO THIS USE PERKINS-DAVIS RETRACTOR DRILL, USE STRAIGHT HAND PIECE WITH DIRECT VISION OR LOW POWER—DRILL PARALLEL AND AWAY FROM AVOIDED STRUCTURES–KEEP YOUR OPENING AS LARGE AS POSSIBLECTEGMEN CAN BE VERY LOW AND VERY SUPERFISCIALCESPECIALLY IN PEDS PTS USE LARGEST BIT TO AVOID SLIPPING—-MAKE LONG STROKES PARALLES TO THE IMPORTANT STRUCTURES—BE BOLD BUT NOT STUPID—DO NOT GET YOURSELF IN A HOLE SAUCERIZE—-MAXIMALLY DEFINE THE TEGMEN DEFINE THE SIGMOID SINUS DISCOVER THE ANTRUM HIGHER POWER—SMALLER BURR AND SUCTION IRRIGATIO N DEFINE ENTIRE SHORT PROCESS OF INCUS VERY CAREFULLY WITH SMALL DIAMOND AND HIGH POWER DEFINE LAT CANAL WELL CAREFULLY DRILL FOR THE FACIAL WITH PRETTY HIGH POWER AND MEDIUM CUTTER IN CAREFULL PARALLES STROKES—TAKE YOUR TIME—-WATCH EVERY THING —YOU WILL FIND IT—MAY THIN THE CANAL AND FIND AND FOLLOW THE CHORDAE TYMPANI TO THE NERVE USE A LOT OF WATER USE THE CURVED HAND PIECE WITH THE MICROSCOPE (DAVIS USES MICROSCOPE ENTIRE CASE)–THIN THE CANAL WALL SO YOU CAN AREAD NEWS PRINT THROUGH IT @ MCABE—PROBABLY NOT A GOOD IDEA AS YOU MAY COMPLETELY DEVASCULARIZE IT—LOOK DOWN IT TO GAIN PERSPECTIVE KEEP THE TM IN VIEW—-AN EXCELLENT LANDMARK—KEEPS YOU SAFE STAY HIGH AND ANT!!!—CAN DRILL INTO THE ROOT OF THE ZYGOMA DEFINE YOUR TEGMEN MASTOIDEUM—TYMPANI (CORRELATES ROUGHLY WITH THE TEMPORAL LINE/LINEA TEMPORALIS)–ROOT OF ZYGOMA–SUP BORDER OF MACEWENS TRIANGLE-(TEGMEN TYMPANI—TEGMEN MASTOIDEUM)—SINODURAL ANGLE OF CITELLI-–(ROUGHLY CORRELATES WITH THE FLOOR OF THE MCF) LATERAL TO THE PLANE BETWEEN THE DIGASTRIC RIDGE, LONG PROCESS OF INCUS, AND LAT SCC IS SAFE MAY ENCOUNTER KOERNER=S SEPTUM (REMNANT OF THE PETROSQUAMOUSAL SUTURE LINE)-–MUST CAREFULLY ASSESS YOUR LEVEL—AVOID THE BEGINNER=S MASTOID ANTRUM AD ADITUS = FIRST DRAINING CELL OF THE MASTOID—THE ONLY ONE AIR CELL THAT IS ALWAYS PRESENT EVEN IN THE MOST SCLEROTIC MASTOID—-DIRECTLY MEDIAL TO MACEWEN=S TRIANGLE SINODURAL ANGLE = ANGLE OF CITELLI—-DEFINE THIS WELL, SHARPEN IT SHORT PROCESS OF INCUS BISECTS THE LAT SCC TRIPLE AS@ TRIANGLE = LAT SCC, SEVENTH NERVE, AND SHORT PROCESS OF INCUS
DONALDSON=S LINE –PARALLEL TO THE LAT SCC AND PERP TO THE POST SCC (BISECTS IT)—POINTS TO THE ELS (? A BIT SUP?) TROUTMAN=S TRIANGLE = LABYRINTH, SIGMOID, SUP. PETROSAL SINUS——USED TO FIND THE ELS ELS IS REALLY SUPERFICIAL TO AND WITHIN A DUPLICATION OF THE DURA DIGASTRIC RIDGE POINTS ANT. TO THE SMF TO THE VERTICLE SEGMENT OF THE FACIAL NERVE—ID IT FROM POST TO ANT OPEN THE ATTIC AS MUCH AS POSSIBLE—-NIP THE HEAD OF THE MALLEUS—STAY ABOVE THE TENSOR TYMPANI TENDON (COCHLEARIFORM PROCESS) OR YOU COMPLETELY DESTABILIZE IT REVERSE THE DRILL SO IT DOES NOT RUN TOWARDS THE INCUS DRILL MEDIAL TO LAT USE A MEDIUM TO LARGE DIAMOND BIT TO ID THE FACIAL NERVE DIAMOND DRILL BIT DOES NOT RUN–-BUT IT DOES GET HOT—CAN USE LOTS OF IRRIGATION AND A SMALL SUCTION USE A BIG DIAMOND TO FIND THE FACIAL NERVE CAROTID A. IS ANT/MEDIAL TO THE ETT TYPANIC PORTION OF THE FACIAL NERVE OVER THE OVAL WINDOW IS MOST LIKELY TO BE DEHISSANT-50-66% JUST INF THE LAT SCC IS THE MOST COMMON SITE FOR INJURY—-BUTTRESS FOR FACIAL RECESS INNER EAR SPIRAL GANGLION = HABENULA PERFORATA POST SCC (SINGULAR NERVE IN SINGULAR CANAL)—-BPPV CRUS COMMUNIS=NON AMPULATED ENDS OF THE VERTICLE SCC=S (POST AND SUP) IAC AND EAC ARE IN A DIRECT PLANE (WITH THE ME AND VESTIBULE INBETWEEN) TROUTMAN=S TRIANGLE = LABYRINTH, SIGMOID, SUP. PETROSAL SINUS utricle = elipticle recess saccule = sherical recess—RIGHT NEAR THE O.W. ampulla on lat(horizontal) canal is ant
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
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?