operative surgery in Ear, nose, throatNT.pptx

OPERATIVE SURGERY ENT

1. OPERATIVE SURGERY “ear” DR. RITESH MAHAJAN

2. OPERATIVE SURGERY OF EAR Myringotomy. Myringoplasty. Tympanoplasty Without Mastoidectomy. Tympanoplasty With Mastoidectomy. Cortical Mastoidectomy (Schwartz Operation). Modified Radical Mastoidectomy. Radical Mastoidectomy. Meatoplasty. Mastoid Obliteration.

3. Myringotomy Surgical incision on the tympanic membrane. To drain effusion of the middle ear. To provide aeration in case of malfunctioning eustachian tube. Ventilation tube (grommet) may also be required in the latter case.

4. Indications Acute suppurative otitis media (a) Severe earache with bulging tympanic membrane. (b) Incomplete resolution. (c) Complications of acute otitis media. Serous otitis media. Aero- otitis media. Atelectatic ear.

5. Contraindications and anaesthesia Suspected intratympanic glomus tumour. Myringotomy in these cases can cause profuse bleeding. In infants and children , always use general anaesthesia. For adults , general anaesthesia is used only when tympanic membrane is acutely inflamed. Myringotomy can be done under local anaesthesia or no anaesthesia at all.

6. Operative procedure Ear canal is cleaned of wax and debris. O perating microscope, sharp myringotome and suction. In ASOM :- Circumferential incision in the posteroinferior quadrant. In SOM :- R adial incision is given in the posteroinferior or anteroinferior quadrant. V entilation tube :- incision just enough to admit the tube .

7. Surgical incisions

8. Post-operative Care Daily mopping of ear discharge in ASOM. In SOM, just leave a wad of cotton wool for 24-48 hrs. Drum incisions usually heal rapidly. Avoid water to enter the ear canal for at least one week. Avoid water till grommet is in place.

9. Complications Injury to incudostapedial joint or stapes. Injury to jugular bulb with profuse bleeding, if jugular bulb is high and floor of the middle ear dehiscent. Middle ear infection.

10. Myringoplasty Closure of perforation of pars tensa of the tympanic membrane is called myringoplasty . restoring the hearing loss and in some cases the tinnitus. checking re-infection from EAC and eustachian tube. checking aeroallergens reaching the exposed middle ear. Myringoplasty can be combined with ossicular reconstruction when it is called tympanoplasty .

11. Contraindications Active discharge from the middle ear. Nasal allergy. Otitis externa. Children below 3 years. Ingrowth of squamous epithelium into the middle ear. When the other ear is dead or not suitable for hearing aid rehabilitation.

12. Operative details Anaesthesia :- Local or general. Position:- Supine with face turned to one side. Graft materials used are: ( i ) Temporalis fascia (most common), (ii) Perichondrium from the tragus, (iii) Tragal cartilage, (iv) Vein.

13. Operative procedure Incisions :- E ndomeatal, E ndaural or Postaural. Underlay Technique :- 1. Harvesting the graft of Temporalis fascia. 2. Preparing the T.M. for grafting. 3. Inspecting the middle ear. 4. Placing the graft.

14. Overlay Technique Temporal fascia or perichondrial graft is harvested. Incision is made in the meatus and meatal skin raised. Graft placed on the outer surface of T.M. Meatal skin removed earlier is now replaced.

15. Overlay Technique Closure of endaural or postaural incision. Mastoid dressing.

16. Post-operative Care Stitches are removed after 5-6 days. Ear pack is removed after 5-6 days without disturbing the gelfoam. Patient is seen at 3 and 6 weeks after operation. Complete epithelialisation of graft takes 6-8 weeks.

17. Complications Underlay Technique. Middle ear becomes narrow. Graft may get adherent to the promontory. Anteriorly, graft may lose contact from the remnant of tympanic membrane leading to anterior perforation.

18. Complications Overlay Technique Blunting of the anterior sulcus . Epithelial pearls. They are epidermal cysts, when squamous epithelium is buried under the graft. Lateralisation of graft :- Graft loses contact from the malleus handle resulting in conductive loss.

19. Other Procedures Splintage with gel foam. Cautery-patching. Fat-graft myringoplasty

20. Cortical Mastoidectomy Cortical mastoidectomy, known as simple or complete mastoidectomy or Schwartz operation. Complete exenteration of all accessible mastoid air cells and convert them into a single cavity. Posterior meatal wall is left intact. Middle ear structures are not disturbed.

21. Indications Acute coalescent mastoiditis. Incompletely resolved AOM with reservoir sign. Masked mastoiditis. As an initial step to perform (a) endolymphatic sac surgery (b) decompression of facial nerve (c) translabyrinthine or retro-labyrinthine procedures for acoustic neuroma.

22. Anatomy Patient lies supine with face turned to one side and the ear to be operated upper-most.

23. Anatomy

24. Steps of Operation Incision. Exposure of mastoid and Mac Ewen's triangle. Removal of mastoid cortex and exposure of antrum. Removal of mastoid air cells. Removal of mastoid tip and finishing the cavity. Closure of wound

25. Post-operative Care Antibiotics started pre-operatively are continued post-operatively for at least one week. Culture swab taken from the mastoid, during operation, may dictate a change in the antibiotic. Drain, if put, is removed in 24-48 hours and sterile dressing done. Stitches are removed on the 6th day.

26. Complications Injury to facial nerve. Dislocation of incus. Injury to horizontal semicircular canal. Injury to sigmoid sinus with profuse bleeding. Injury to dura of middle cranial fossa. Post-operative wound infection and wound break-down.

27. Radical Mastoidectomy It is a procedure to eradicate disease from the middle ear and mastoid without any attempt to reconstruct hearing. Posterior meatal wall is removed and the entire area of middle ear, attic, antrum and mastoid is converted into a single cavity. All remnants of tympanic membrane, ossicles (except stapes footplate) and mucoperiosteal lining are removed.

28. Radical Mastoidectomy Eustachian tube is obliterated by a piece of muscle or cartilage. Aim of the operation is to permanently exteriorise the diseased area for inspection and cleaning. The radical mastoidectomy is infrequently required these days.

29. Indications When all cholesteatoma cannot be safely removed. Revision cases. As an approach to petrous apex. Removal of glomus tumour. Carcinoma middle ear.

30. Anatomy

31. Steps of Operation Anesthesia and position. Incision. Retraction of tissues and exposure of mastoid. Removal of bone and exposure of attic and antrum. Removal of the "bridge" and the buttresses. Lowering the facial ridge.

32. Anatomy

33. Steps of Operation Toilet of middle ear. Inspection of the cavity and irrigation. Lowering the facial ridge. Inspection of the cavity and irrigation. Meatoplasty. Obliteration of the cavity. Closure of wound.

34. Post-operative Care Dressing first dressing is done on 3rd or 4th day. Second dressing is done on 6th or 7th day when stitches are removed and meatal pack is changed. Antibiotic A suitable antibiotic is given for about a week. Cavity care any granulation tissue which delays epithelialisation is removed or cauterised.

35. Complications Facial paralysis. Perichondritis of pinna. Injury to dura or sigmoid sinus. Labyrinthitis, if stapes gets dislocated. Severe conductive deafness of 50 dB or more. Cavity problems :- Twenty five percent of the cavities do not heal and continue to discharge, requiring regular after-care.

36. Modified Radical Mastoidectomy It is a modification of radical mastoidectomy where as much of the hearing mechanism as possible is preserved. The disease process which is often localised to the attic and antrum is removed. The whole area fully exteriorised into the meatus by removal of the posterior meatal and lateral attic wall.

37. Indications Cholesteatoma confined to the attic and antrum. Localised chronic otitis media. Irreversibly damaged tissues are removed. Preserving the rest to conserve or reconstruct hearing mechanism.

38. Steps of Operation Incision, postaural or endaural. Retraction of soft tissues and exposure of mastoid area. Removal of bone and exposure of antrum and attic. Steps 2 and 3 are the same as in radical mastoidectomy. Removal of diseased tissue . Cholesteatoma, granulations or unhealthy mucosa is removed. Incus and head of malleus often require removal.

39. Anatomy Anaesthesia and position.

40. Steps of Operation Facial ridge is lowered. Mastoid cavity is smoothened with polishing burr. Reconstruction of hearing mechanism. Reconstruction of tympanic membrane or ossicular chain, if damaged, can also be done (mastoidectomy with tympanoplasty operation). Meatoplasty and closure of wound is same as in radical mastoidectomy.

41. Post-operative Care & Complications Dressing. Antibiotics. Cavity care. Facial paralysis. Perichondritis of pinna. Injury to dura or sigmoid sinus. Labyrinthitis, if stapes gets dislocated. Severe conductive deafness of 50 dB or more.

42. Meatoplasty Meatoplasty is an operation in which a crescent of conchal cartilage is excised to widen the meatus. It is combined with all canal wall down procedures. It is also done as an isolated procedure in a sagging auricle seen in older people. Sagging auricle obstructs the ear canal and causes hearing loss and retention of wax.

43. Mastoid Obliteration It is an operation to eradicate mastoid disease, when present, and to obliterate the mastoid cavity. Obliteration of mastoid cavity is done with pedicled temporalis muscle or musculofascial tissue raised as flaps.

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