CSOM SURGERIES

CSOM SURGERIES

1. CSOM SURGERIES Dr Harjitpal Singh Assistant Professor(ENT), Dr RKGMC, Hamirpur

2. CHRONIC SUPPURATIVE OTITIS MEDIA CSOM is a long standing infection of a part or whole of the middle ear cleft, characterized by ear discharge and a permanent perforation Types of CSOM: 1. Tubotympanic 2. Atticoantral

3. OBJECTIVES OF SURGERY FOR CSOM Eradication of disease Prevention of recurrence Prevention of complications that can occur due to CSOM Restoration of hearing

4. TREATMENT CSOM- UNSAFE Surgical treatment Reconstructive surgery

5. MASTOID SURGERY

6. MASTOID SURGERY( cont ) CANAL WALL UP (CWU) 1. Simple/ cortical/ complete/ Schwartz's mastoidectomy 2. Classic Intact Canal Wall Mastoidectomy/ Combined Approach Tympanoplasty (CAT) CANAL WALL DOWN (CWD) 1. Atticotomy 2. Atticoantrotomy 3. Radical Mastoidectomy 4. Modified Radical Mastoidectomy/ B ondy’s Procedure 5. Retrograde Mastoidectomy

7. MASTOID SURGERY( cont ) CHOICE OF SURGERY E xtent of disease H ealth S tatus of contralateral ear S urgeons experience P atient preference

8. MASTOID SURGERY( cont )

9. INTACT CANAL WALL SURGERIES Cortical mastoidectomy Combined approach tympanoplasty (CAT)

10. PRE-OPERATIVE EVALUATION Diagnosis of cholesteatoma : Well taken history Examination under microscope OTHERS: Hearing assessment (poorer ear operated 1 st ) Radiograph & imaging studies(suspected complications) Patient counselling

11. CORTICAL MASTOIDECTOMY Other terminologies: Simple mastoidectomy Schwartz mastoidectomy Conservative mastoidectomy Complete mastoidectomy

12. STEPS OF CAT Cortical mastoidectomy Anterior Tympanotomy : via tympanomeatal flap Posterior Tympanotomy : via facial recess approach Tympanoplasty

13. HISTORY OF CORTICAL MASTOIDECTOMY Hippocrates proposed the idea 16 th century: Ambrose Pare advised mastoid exploration for young king of France 1649:Rialon : described mastoid surgery 1736: Jean Petit of paris performed it successfully

14. HISTORY OF CORTICAL MASTOIDECTOMY 1853 : William Wilde recommended incision 1873 : schwartze described indications & technique of simple mastoidectomy 1950: Janssen described Intact canal wall mastoidectomy.

15. INDICATIONS OF CORTICAL MASTOIDECTOMY Mastoid as primary pathology Acute coalescent mastoiditis & CSOM Lateral sinus thrombosis Epidural abscess Initial step of facial recess approach As part of neurotological procedure Labryinthectomy Decompression of endolymphatic sac Retrolabrynthine vestibular nerve section Translabrynthine excision of acoustic neuroma Facial nerve decompression Cochlear implantation

16. ANAESTHESIA General Anaesthesia( preferred) /Local anaesthesia Muscle Relaxants avoided( if facial nerve monitoring) Nitrous oxide stopped 30 minutes before; if graft has to be kept

17. POSITIONING OF THE PATIENT Patient is placed closed to the edge of the table, Patient’s body strapped on table with both arms padded and tucked closed to body. Head turned approx 120 degrees away from surgeon and is supported with a folded towel placed b/t table and contralateral cheek. Operating table which can rotate along its long axis. Hydraulic chair.

18. PATIENT PREPARATION & POSITIONING Hair shaved 2cm superior & 1cm posterior to auricle Surgical site prepared with alcohol & betadine solution Square off site with clear adhesive drapes. Perioperative / prophylactic antibiotic use debated

19. STEPS OF CORTICAL MASTOIDECTOMY STEP 1 2% lidocaine with 1:100,000 epinephrine infiltrated

20. STEPS OF CORTICAL MASTOIDECTOMY STEP 2 Post aural / william wilde incision Superior: root of helix Inferior : to lateral surface of mastoid tip Posterior: 8-10 mm from post auricular groove Post aural incision in a)adults b) children

21. STEPS OF CORTICAL MASTOIDECTOMY <2 years Incision posterior & superior as: Stylomastoid foramen shallow Tympanic ring incomplete Mastoid not pneumatized Incision in children

22. STEPS OF CORTICAL MASTOIDECTOMY STEP 3 In superior aspect of skin incision Subcutaneous tissue divided Temporalis fascia harvested

23. STEPS OF CORTICAL MASTOIDECTOMY STEP 4 T – SHAPED INCISION OVER MUCOPERIOSTEUM

24. STEPS OF CORTICAL MASTOIDECTOMY STEP 5 Mucoperiosteum overlying mastoid elevated with periosteum elevator

25. SPINE OF HENLE

26. STEPS OF CORTICAL MASTOIDECTOMY STEP 6 Surgical landmarks on lateral cortical wall identified MacEwen’s triangle identified

27. Macewen’s / Suprameatal triangle/ fossa mastoidea OUTLINED BY : line parallel to Linea temporalis line perpendicular to linea temoralis posterior to EAC line tangential to EAC coursing through spine of henle

28. STEPS OF CORTICAL MASTOIDECTOMY STEP 7 : Drilling 1 st cut: parallel to linea temporalis 2 nd cut : tangent to EAC 3 rd cut : parallel to course of sigmoid sinus connecting 1 st to cuts

29. STEPS OF CORTICAL MASTOIDECTOMY DRILLING Under microscope Various sized cutting burrs Start with largest Continuous suction irrigation : Cool the bone Keep field clean Prevent clogging of burr by bone dust

30. STEPS OF CORTICAL MASTOIDECTOMY STEP 8 Lateral surface of temporal bone saucerized : Superior: middle fossa plate Inferior : mastoid tip Anterior : EAC Posterior : sigmoid sinus

31. BOUNDARIES OF MASTOID CAVITY Superior: Dural or Tegmen plate Anterior: Posterior wall of external auditory canal Inferior: Digastric ridge Posterior : Sigmoid sinus plate Medially: Lateral semicircular canal

32. STEPS OF CORTICAL MASTOIDECTOMY STEP 9 Structures to be skeletonized : Middle fossa plate Sigmoid sinus Mastoid tip Posterior canal wall Bony labyrinth

33. STEPS OF CORTICAL MASTOIDECTOMY STEPS 10 Expose & identify: 1.incus 2.Aditus ad antrum 3.Fossa incudis 4. Course of facial nerve

34. STEPS OF CORTICAL MASTOIDECTOMY STEP 11 SURGICAL SITE : profusely irrigate mastoid cavity Haemostasis ensured Wound site closed in layers Mastoid dressing/ Glasscock pressure dressing applied

35. CORTICAL MASTOIDECTOMY KEY POINTS Source of bleeding while drilling : Marrow space Granulation tissue Dura vessels Bleeding controlled by: Continue drilling bone wax used to control bleeding from marrow spaces Diamond burr controls bleed from small blood vessels Monopolar cautery over suction tip Bleeding in facial nerve vicinity/ dura controlled by gelfoam ;

36. COMBINED APPROACH TYMPANOPLASTY (CAT) OTHER NAMES: Intact canal wall tympanoplasty with mastoidectomy Closed cavity tympanoplasty with mastoidectomy Facial recess approach Posterior tympanotomy

37. COMBINED APPROACH TYMPANOPLASTY (CAT) IDEAL CANDIDATE WELL AERATED MIDDLE EAR CLEFT  FUNCTIONAL EUSTACHIAN TUBE LARGE PNEUMATIZED MASTOID FOLLOW UP POSSIBLE LIMITED DISEASE

38. STEPS OF FACIAL RECESS APPROACH Cortical mastoidectomy Attention turned to facial recess Medial: Facial nerve (mastoid segment) Lateral: Chorda tympani Superior :Fossa incudis

39. COMBINED APPROACH TYMPANOPLASTY (CAT) Facial recess EAC FACIAL RECESS OPENED Facial Recess air cells followed to gain access into middle ear( progressively smaller burrs) Bone over facial nerve removed until thin shell of bone overlies it Approx 2mm opening can be obtained through facial recess DIAMOND BURR WITH COPIOUS IRRIGATION:AVOID DIRECT TRAUMA & HEAT TRANSMISSION

40. COMBINED APPROACH TYMPANOPLASTY (CAT) Facial nerve or cholesteatoma? Probe with needle  Facial nerve bounces back Cholesteatoma / mucosa doesn’t bounce

41. STRUCTURE VISIBLE THROUGH FACIAL RECESS INCUS INCUDOSTAPEDIAL JOINT STAPES SUPRASTRUCTURE PROMONTORY ROUND WINDOW NICHE

42. STRUCTURE NOT VISUALIZED THROUGH FACIAL RECESS Oval window Stapes footplate Anterior epitympanum Sinus tympan i ACCESSED THROUGH EAR CANAL

43. FACIAL RECESS & SINUS TYMPANI LATERAL MEDIAL ct SINUS TYMPANI

44. COMBINED APPROACH TYMPANOPLASTY (CAT) IF INCUS ERODED BY CHOLESTEATOMA-> INCUS REMOVED BONY BRIDGE ON INFERIOR ASPECT OF FOSSA INCUDIS REMOVED HANDLE OF MALLEUS REMOVED VISUALIZE & REMOVE DISEASE FROM ANTERIOR EPITYMPANUM

45. COMBINED APPROACH TYMPANOPLASTY (CAT) Plastic sheeting & gel foam placed in middle ear Tympanic membrane reconstructed Wound site closed in layers

46. CANAL WALL DOWN SURGERY Radical mastoidectomy Modified radical mastoidectomy Bondy’s mastoidectomy

47. HISTORY OF CANAL WALL DOWN MASTOID SURGERY 1873: Von Troltsch 1873: Jansen: MRM 1889: Radical term for posterior canal wall removal(Von Bergmann) 1893: Zaufal & Stacke ; radical mastoidectomy 1910: Bondy’s modification 1940: Boettcher used drill

48. RADICAL MASTOIDECTOMY Radical mastoidectomy is a canal wall down mastoidectomy P erformed to eradicate disease from middle ear cleft. Mastoid cavity, tympanum and EAC are converted into a common cavity exteriorised through the EAC. Wherein the structures of tympanic cavity (remnants of the incus and malleus, and the drum remnant) are removed.

49. RADICAL MASTOIDECTOMY INDICATIONS: Unresectable cholesteatoma extending down the Eustachian tube or into the petrous apex Promontory cochlear fistula caused by cholesteatoma Chronic perilabyrinthine osteitis or cholesteatoma that cannot be removed and must be cleaned or inspected periodically Resection of temporal bone neoplasms with periodic monitoring

50. RADICAL MASTOIDECTOMY

51. RADICAL MASTOIDECTOMY Perform cortical mastoidectomy . Lower facial ridge & break facial bridge. Remove cholesteatoma & granulations Remove normal middle ear mucosa, T.M. remnant & ossicles (except stapes footplate). Close Eustachian tube opening Mastoid, E.A.C. & middle ear become single cavity.

52. MODIFIED RADICAL MASTOIDECTOMY It is done where the disease is localized to attic and mastoid antrum. MRM is a surgical procedure where the disease process is eradicated from the middle ear cleft. Followed by converting the mastoid cavity, middle ear and EAC into a single, smooth, self-cleansing cavity exteriorized through EAC. In this operation healthy and normal middle ear structures such as mucosa, ossicles and remnant of tympanic membrane are preserved with no compromise on the removal of disease.

53. MODIFIED RADICAL MASTOIDECTOMY ABSOLUTE INDICATIONS: Unresectable disease Unreconstructable Posterior canal wall Failure of first stage CWU procedure because of poor E T function. Inadequate Patient Follow up.

54. MODIFIED RADICAL MASTOIDECTOMY RELATIVE INDICATIONS: Disease in only hearing ear or in a dead ear. Medical illness Severe otologic or CNS complications Neoplasms Poor E T function.

55. MODIFIED RADICAL MASTOIDECTOMY CONTRAINDICATIONS: Chronic otitis media without cholesteatoma Acute otitis media with coalescent mastoiditis , persistent secretory otitis media, or Chronic allergic otitis media. Tuberculous otitis media.

56. MODIFIED RADICAL MASTOIDECTOMY Intact canal wall mastoidectomy is performed. Then lowering of canal wall is performed. Area of canal wall to be lowered consists of: Anterior buttress : tympanosquamous suture Posterior buttress: facial ridge & intervening bridge Scutum : lateral epitympanic wall

57. MODIFIED RADICAL MASTOIDECTOMY anterior buttress lowered to anterior canal wall posterior buttress removed to level of facial nerve

58. MODIFIED RADICAL MASTOIDECTOMY Drilling over posterior canal wall: Large cutting burr Bone removal begun inside of EAC on anterosuperior surface Direction :parallel to nerve superior to inferior

59. MODIFIED RADICAL MASTOIDECTOMY As bone overlying malleus, incus & facial nerve is thinned AVOID: Inadverent drilling Inadverent pressure medially The last bridge of the posterior canal wall is removed while using a curette to protect the ossicles and facial nerve.

60. MODIFIED RADICAL MASTOIDECTOMY Bone overlying vertical segment of facial nerve: facial ridge  lowered Remove cholesteatoma and granulation tissue from mastoid and middle ear cavity. Preserve healthy mucosa, TM remnant and ossicles. Perform tympanoplasty. Perform concho-meatoplasty .

61. MODIFIED RADICAL MASTOIDECTOMY KEY POINTS In addition to adequate disease removal 4 basic steps for trouble free mastoid: Adequate saucerization (no overhang) Adequately lowered facial ridge Mastoid tip management: if pneumatized (drill or amputate) Adequate meatoplasty

62. MEATOPLASTY One percent lidocaine with 1:100,000 epinephrine is infiltrated into the conchal bowl. With a finger in the conchal bowl, a semilunar incision is made into the cartilage posteriorly until the knife tip is felt through the anterior skin.

63. MEATOPLASTY This crescent-shaped cartilage measures about 1.5 x 2 cm

64. BONDY’S MODIFIED RADICAL MASTOIDECTOMY Superior and posterior EAC removed to exteriorize cholesteatoma in mastoid & attic to EAC HALLMARK : Tympanic membrane & middle ear not disturbed . Completed Bondy -modified radical mastoidectomy .  

65. BONDY’S MODIFIED RADICAL MASTOIDECTOMY DISEASE TO BE REMOVED FROM : FACIAL RECESS SINUS TYMPANI SINODURAL ANGLE ANTERIOR ATTIC ALONG FACIAL NERVE ALONG STAPES MASTOID TIP

66. ATTICOTOMY INDICATION: Limited attic cholesteatoma confined to central epitympanic area. Edges of scutal defect drilled with diamond burr & gradually widened. Superior wall thinned Margins of cholesteatoma sac identified & exteriorized.

67. ATTICOANTROSTOMY It is an extension of the atticotomy in a posterior direction through the transmeatal route, in which lateral attic and aditus walls are removed, and the antrum is entered. It can be performed through the transcortical route, but is usually performed through a transmeatal route.

68. POST OPERATIVE CARE Foul smelling discharge: remove pack. Send for C/S Remove stitches on 7 th POD & pack on 10 th POD Keep ear dry Regular follow up after discharge. PODry Regular follow up after discharge

69. FOLLOW UP 6-10wks time period for cavity to heal. Every 2-3 wks cavity debrided & granulation tissue removed Then follow up every 6mths – 1 yr depending on condition of mastoid .

70. DISCHARGING CAVITY-CAUSES 1 . Inadequate concho-meatoplasty 2. Recurrence of cholesteatoma 3. Persistent infection: petrositis , T.B., sinusitis 4. Persistent allergy 5. Retained foreign body: cotton ball 6. Persistent extra- dural abscess 7 . Residual cholesteatoma: facial ridge, facial bridge, anterior & posterior buttress, mastoid tip, sinus tympani, anterior epitympanum .

71. COMPLICATIONS OF SURGERY Injury to facial nerve Injury to HSCC Injury to sigmoid sinus Injury to dura SNHL RECURRENCE/RESIDUAL DISEASE discharging cavity Perichonderitis

72. INJURY TO FACIAL NERVE Intra op FN trauma: decompress proximal & distal Post op <immediate>: make sure FN was identified + integrity tested intra op yes Observe few hrs  effect of LA vanishes Tight mastoid dressing may press on exposed FN remove pack Incomplete palsy  put on steroids Progression to complete palsy  re-exploration NOTE: assistance with experienced colleague must!!

73. INJURY TO DURA MINOR: concealed by surrounding arachnoid tissue Remove surrounding 5mm bone to inspect dura & brain Fascia graft between normal dura & surrounding bone Macerated muscle Hydroxypatite bone cement with fascia over it.

74. INJURY TO DURA

75. INJURY TO SIGMOID SINUS Press with finger immediately Remove suction aspirator Small laceration : bipolar cautery / thrombin soaked gelfoam Large laceration: large gelfoam over surface opening; if surrounding bony cover present ;bone wax used .

76. INJURY TO SIGMOID SINUS

77. INJURY TO HSCC IMMEDIATELY SEAL WITH : Facial plug Bone wax Muscle plug IATROGENIC LABRYNTHINE FISTULA : LSCC Stapes footplate

78. SNHL Etiology : Opening labyrinth Manipulation of ossicles Drilling on ossicles Unidentified causes

79. RECONSTRUCTIVE SURGERIES

80. MYRINGOPLASTY Procedure used to repair a perforated tympanic membrane using a graft material, without need to examine the middle ear. Advantages:- Restoring the hearing loss Checking repeated infections from EAC and ET Checking aeroallergens reaching the exposed middle ear mucosa leading to persistent ear discharge.

81. SURGICAL APPROACHES FOR MYRINGOPLASTY Post aural approach Endomeatal or transcanal approach Endaural approach

82. ENDOMEATAL OR TRANSCANAL APPROACH ROSEN’S INCISION

83. ENDAURAL APPROACH

84. POST AURAL / WILDE’S INCISION

85. TYMPANOTOMIES Opening the tympanic cavity by elevating a tympanomeatal flap together with the fibrous annulus . Tympanotomies can be divided into: Posterior tympanotomy - 12–o’clock to 6-o’clock posteriorly ( rosen incision). Inferior tympanotomy – 9-o’clock to 3-o’clock incision inferiorly. Anterior tympanotomy – 12-o’clock to the 6-o’clock incision about 5mm lateral to annulus anteriorly . Superior tympanotomy - 9-o’clock to 3-o’clock incision about 5mm lateral to shrapnell’s membrane.

86. GRAFT MATERIALS AUTOGRAFT (AUTOGENOUS GRAFT) – graft from same person. These include: Temporalis muscle fascia Tragal perichondrium Conchal perichondrium Tragal or conchal cartilage Periosteum (mastoid process and temporal squama ) Vein ( great saphenous vein, cubital vein) Fatty tissue (ear lobule) Subcutaneous tissue Fascia lata Ear canal skin

87. GRAFTING TECHNIQUES OVERLAY TECHNIQUE UNDERLAY TECHNIQUE

88. OVERLAY TECHNIQUE This technique is used when there is no remnant of the tympanic membrane. The graft rests over the anterior and the posterior tympanic sulcus and underneath the malleus handle. The edges of the graft are covered by meatal skin.

89. COMPLICATIONS OF OVERLAY TECHNIQUE Blunting of anterior sulcus . Epithelial pearls – they are epidermal cyst, when squamous epithelium is buried under the graft. Lateralisation of graft- graft loses contact from the malleus handle resulting in conductive loss.

90. UNDERLAY TECHNIQUE The presence of an anterior remnant of the tympanic membrane is required for this type of fascial graft. The graft is placed under the anterior remnant of the tympanic membrane and over the posterior tympanic sulcus . The graft lies under the malleus handle.

91. COMPLICATIONS OF UNDERLAY TECHNIQUE Middle ear becomes narrow. Graft may get adherent to promontory. Anteriorly graft may loose contact from remnant of tympanic membrane leading to anterior perforation.

92. FAT GRAFT MYRINGOPLASTY

93. OTHER TECHNIQUES

94. OSSICULOPLASTY Aim is to surgically optimize the hearing mechanism Performed in otherwise healthy ears or in conjunction with tympanoplasty and mastoidectomy for chronic ear disease

95. TYMPANOPLASTY

96. TYMPANOPLASTY TYMPANOPLASTY includes : Canaloplasty ( widening of bony part of the external auditory canal) Myringoplasty (closure of the eardrum perforation in cases with a normal ossicular chain and without any other surgical procedures in the tympanic cavity or middle ear) Ossiculoplasty ( reconstruction of ossicular chain)

97. AIMS OF TYMPANOPLASTY Eradication of disease Restoration of tympanic membrane Reconstruction of a sound transformer mechanism

98. OBJECTIVES OF TYMPANOPLASTY IN DECREASING ORDER OF PRIORITY elimination of disease to produce a safe and dry ear; alteration of anatomy to prevent recurrent disease, and to optimize cleaning and otologic monitoring; reconstruction of the middle ear to achieve serviceable and stable postoperative hearing

99. INDICATIONS FOR TYMPANOPLASTY Tympanic membrane perforations and associated hearing loss with or without middle ear pathology such as tympanosclerosis , small retraction pockets , and cholesteatomas .

100. CONTRAINDICATIONS ABSOLUTE: Poor general health Malignant tumours of outer / middle ear Uncontrolled cholesteatoma Unusual infections like malignant otitis externa Complications of chronic ear disease such as meningitis , brain abscess ,or lateral sinus thrombosis If it is the only or significantly better hearing ear.

101. CONTRAINDICATIONS RELATIVE: Nonfunctioning eustachian tube Nasal allergy Chronic Otitis externa Acute exacerbation of chronic otitis media , chronic mucoid discharge associated with allergic rhinosinusitis

102. PREOPERATIVE EVALUATION Complete history and head and neck examination Otoscopic examination , best accomplished by operating microscope Audiogram ,including PTA and air bone conduction thresholds as well as speech discrimination scores.

103. ANAESTHESIA GENERAL ANESTHESIA :- Extensive removal of tympanic cavity mucosa or tympanic cavity cholesteatoma Any surgery in the anterior tympanum or tympanic orifice of the Eustachian tube Cases requiring mastoidectomy or reconstruction of the ear canal Children

104. ANAESTHESIA Uncooperative adults, apprehensive adults Patients who spontaneously prefer or request GA Any surgery lasting more than 1 ½ - 2 hours. Revision tympanoplasties where major pieces of temporal muscle fascia have already been harvested previously LOCAL ANESTHESIA :– Limited to cooperative adults with dry, noninfected ears and no evidence of mastoid disease.

105. TYPES OF TYMPANOPLASTY ACCORDING TO WULLSTEIN (1968)

106. TYPE I - TYMPANOPLASTY TYPE I – perforation in tympanic membrane repaired with a graft. Intact ossicular chain . Myringoplasty

107. TYPE II - TYMPANOPLASTY TYPE II – defective or absent malleus handle, but intact incudostapedial joint. The fascia is placed on the lenticular process of the incus . Myringoincudopexy

108. TYPE III – malleus and incus are absent. Graft is placed directly on the stapes head. Myringostapediopexy producing a shallow middle ear and a collumella effect. TYPE III - TYMPANOPLASTY

109. TYPE IV - TYMPANOPLASTY TYPE IV – only the foot plate of stapes is present . It is exposed to the external ear and graft is placed between the oval and round windows. A narrow middle ear ( cavum minor ) is thus created, to have an air pocket around the round window

110. TYPE V - TYMPANOPLASTY TYPE V – stapes footplate is fixed but round window is functioning. Another window is created on horizontal SCC and covered with a graft. F enestration Operation

111. TECHNIQUES OF TYMPANOPLASTY (A) Type I. Repair of tympanic membrane (TM) with temporalis fascia .

112. (B) Type III: minor columella . Ossicular strut or partial ossicular replacement prosthesis (PORP) is placed between stapes head and manubrium /TM .

113. (C) Type III: major columella . Total ossicular replacement prosthesis (TORP) is placed from stapes footplate to the manubrium /TM .

114. ( D) Type III: S tapes columella . Performed with canal wall-down (CWD) mastoidectomy and obliteration of mastoid. Thin cartilage disk and temporalis fascia are placed on stapes head.

115. ( E) Type IV. Round window is acoustically shielded by thick cartilage and temporalis fascia while footplate is covered with thin skin graft. Also performed with CWD mastoidectomy

116. (F) Type V. Similar to type IV, except for total stapedectomy and footplate replacement by an adipose graft.

117. POSTOPERATIVE CARE PRECAUTIONS Do not drive home after discharged the next morning No air travel until 4 weeks after surgery Do not blow nose until ear is healed When sneezing, keep mouth open Avoid water entering ear canal Oral antibiotics First postoperative visit after one week The gelfoam over graft is gently suctioned away, if still present , at the second visit 3 to 4 weeks later. Improvement in hearing can be noticed 6 to 8 weeks after surgery, but maximum may take 4 to 6 months

118. COMPLICATIONS OF TYMPANOPLASTY Intraoperative Bleeding Facial Nerve Injury Wound infection / Perichondritis Wound Hematoma Chorda Tympani Nerve Injury Tympanoplasty Failure Recurrent / Residual Middle Ear Cholesteatoma Sensorineural Hearing Loss / Dizziness.

119. THANK YOU