Ear and Nasal Surgery

audiometry

tests hearing by emitting a tone at different pitches and volume, patient wears headphones and indicates hearing a tone by raising their hand

otoscope

handheld lighted instrument used to view the external auditory canal

tuning fork

2 pronged metal device that emits a clear tone when tapped, measures bone conduction

CT scan

defines bony structures

MRI

defines soft tissue

tympanogram

measures vibrations of tympanic membrane by placing a probe against the tympanic membrane

electronystagmogram (ENG)

tests balance mechanism of inner ear

3 types of incisional approaches for ear surgery

endaural, transcanal, and postauricular

endaural incision

thru the ear canal

transcanal incision

thru ear canal

postauricular incision

behind the ear

what do power tools only use during ear surgery?

burrs (rotating) (handpiece is usually angled)

what can be used to monitor facial nerves?

nerve stimulator

why should nitrous oxide be avoided during ear surgery?

may increase middle ear pressure

what drapes are used for draping for ear surgeries?

turban on head or 4 blue towels, U-drape or fenestrated ear drape

what dressings are used for ear surgery?

cotton ball in ear canal, mastoid dressing

myringotomy with tube insertion

incision into tympanic membrane with insertion of a drainage (vent) tube (general anesthesia), from 12 months (may be younger) to adult

what is the goal of myringotomy with tube insertion procedure

to decrease inner ear pressure and reestablish drainage into eustachian tube

are gowns commonly worn for a myringotomy procedure?

no (just sterile gloves)

what instruments are used for a myringotomy procedure?

ear speculums, myringotomy knife, wax loop, alligator forceps, rosen needle (ear pick), frazier suction tip, silastic tubing, cotton ball, microscope used

procedural steps for myringotomy?

ear wax removed, tympanic membrane incised, middle ear fluid suctioned, tube placed, and dressings placed

what are 2 other names for a myringotomy procedure?

paracentesis and tympanotomy

how long does it take for a myringotomy incision to heal?

within 24 hours

how long does it take for myringotomy tube to fall out on its own as the incision heals?

6 months to a year

what is important to never touch myringotomy tubes and how should they be grasped?

never touch with gloves, use alligator forceps

myringotomy with fat graft

done to repair tympanic membrane after ear tubes have been removed, fat graft is taken from behind the ear and placed over the tympanic membrane defect

what instruments are used for myringotomy with fat graft to obtain the graft?

#3 with 15 blade, iris scissors, adson with teeth, and suture for skin closure

stapedectomy

surgical removal of stapes with insertion of prosthesis (usually seen in adults age 18-45), uses local with sedation, plastic ear drape and body sheet

what is the goal of stapedectomy

to improve/restore hearing by re-establishing the linkage between incus and oval window

what is a stapedectomy indicated for

for patients with chronic, progressive deafness due to otosclerosis (formation of spongy bone with-in ear which prevents transmission of soundwaves)

what grafts may be used for stapedectomy

artificial prosthesis (many types), vein graft from hand or fascia, perichondrium tissue from behind the ear

instruments used for stapedectomy

stapedectomy tray, ear speculum holder, implants, xomed or Jordan day ear still, microscope

procedural steps for stapedectomy

tympano-meatal flap is created and elevated, annulus is identified and elevated, bone curretted from annulus, stapes are removed, prosthesis inserted, tuning fork (determine status), ear packed with cotton ball

what dressings are used for stapedectomy

cotton ball, mastoid dressing, fluffs, ABD, kling or kerlix roll, tape

mastoidectomy

removal of diseased bone of the mastoid process and mastoid space, performed for cholesteatoma and chronic middle ear and mastoid infection (uses nerve monitoring to identify and preserve facial nerves)

cholesteatoma

accumulation of squamous epithelium in middle ear and mastoid, occasionally forms a cyst-like mass, acts as a foreign body, producing bony erosion to middle ear and mastoid

what are the 3 types of mastoidectomy

simple, modified radical, and radical

simple mastoidectomy

removal of diseased mastoid bone (ossicles, eardrum, and canal wall left intact)

modified radical mastoidectomy

removal of diseased mastoid bone and some of the ossicles and canal wall (tympanic membrane and rest of ossicles left intact)

radical mastoidectomy

removal of mastoid air cells, tympanic membrane, ossicles and auditory canal walls (rarely performed because it may damage facial nerve)

what anesthesia and incisional approaches can be used for a mastoidectomy?

general, endaural (inside ear) and postauricle incisions (behind ear, most common because it allows for better exposure)

what instruments and dressings are used for mastoidectomy

ear tray, ear picks, alligator forceps, drill, rongeurs, cautery, bone wax, gelfoam, microscope, impregnated antibiotic gauze, mastoid dressing

what are key notes to remember about mastoidectomy procedure?

irrigate while surgeon drills, cut gelfoam into very small pieces (place in petri dish, have bone wax ready

tympanoplasty

surgical restoration of a diseased or injured tympanic membrane and/or middle ear structure due to chronic otitis media or cholesteatoma

what is the goal of a tympanoplasty

repair perforation in the TM (tympanic membrane), repair sound transmitting mechanism, improve hearing

how is the type of tympanoplasty performed determined?

according to the degree of damage

what anesthesia and instruments are used for a tympanoplasty?

local with IV sedation or general, uses ear tray, micro instruments, picks, alligator forceps, power drill, gelfoam, paper patch, microscope

procedural steps for tympanoplasty?

diseased tympanic membrane removed, graft taken from fascia behind ear or arm vein, graft is moistened and flattened with 2 tongue blade or metal graft holder (graft dried and pressed which may use heat lamp), gelfoam or paper patch are used to keep it in place, mastoidectomy dressing applied

Acoustic neurectomy (vestibular schwannomas)

benign tumors that grow along the branches of the 8th cranial nerve, arise from schwann cells that wrap around and support nerve fibers, diagnosed with audiometry test and MRI with contrast

what are symptoms of vestibular schwannomas?

most common is hearing loss on side of growth, dizziness, balance issues, tinnitus, facial numbness from tumor pressing on the trigeminal nerve, facial twitching from compression of facial nerve, swallowing difficulties for pressure on vagus and hypoglossal nerves

who performs an acoustic neurectomy from vestibular schwannomas?

a neurosurgeon

what are the 3 incisional approaches for acoustic neurectomy

suboccipital, translabyrinthine craniotomy, and middle fossa craniotomy

suboccipital incisional approach (retrosigmoid craniotomy)

removing a section of the occipital bone

translabyrinthine craniotomy incisional approach

access through the inner ear- requires going through structures so hearing is not preserved

middle fossa craniotomy incisional approach

preserves hearing but greater risk to facial nerve

ossicular chain reconstruction

performed to improve conductive hearing, replace a damaged malleus or incus bone or both (damage from injury or infection), often done in conjunction with a tympanoplasty or mastoidectomy

procedural steps for ossicular chain reconstruction

incision, eardrum retracted to one side, all or parts of damage bones are removed, bones may be rebuilt with synthetic material or replaced with prosthesis, eardrum is repositioned

cochlear implant system (intensive teaching for interpretation of sounds)

sound is transformed into electrical system in the speech processor, signal is transmitted from external to internal conduction coil (receiver placed over mastoid bone), coil is connected to electrode implanted near cochlear nerve

implantable hearing aid names

bone anchored hearing aid (BaHA) and semi-implantable hearing aid

bone anchored hearing aid (BaHA)

used for moderate to severe conductive hearing loss, combines a sound processor with a titanium fixture implanted behind the ear, allows the bone to transfer sound to a functioning cochlea (direct bone conduction)

semi-implantable hearing aid

used in middle ear-directly stimulates the ossicles, consists of an audio processor, internal receiver (implanted in temporal bone), conductor link and floating mass transducer (attached to incus)

examples of other ear diseases and disorders

ruptured tympanic membrane (perforated eardrum), otitis externa, tinnitus, vertigo, and meniere’s disease

ruptured tympanic membrane (perforated eardrum)

typically a ruptured eardrum will heal on its own without treatment within a couple of months, can lead to complications such as middle ear infection, may require surgery to repair the damage to the eardrum

otitis externa

inflammation of the outer ear and ear canal, commonly known as “swimmer’s ear”, treatment includes ear drops, either antibacterial or antifungal

tinnitus

perception of sound within the human ear (ringing of the ears) when no actual sound is present, it is common affecting 10-15% of people, no effective medications

vertigo

patient inappropriately experiences the perception of motion (usually a spinning motion) due to dysfunction of the vestibular system, treatment options depend on the underlying causes

meniere’s disease

a disorder of the inner ear that can affect hearing and balance to a varying degree, characterized by episodes of vertigo, low-pitched tinnitus, and hearing loss, NO CURE (only various ways to manage the disease and minimize symptoms)

rhinologic and sinus surgery diagnostic procedures and tests

direct vision, mirror examination (nasopharynx and posterior nasal cavity), angiography, radiography, CT

angiography for rhinologic and sinus

demonstrates blood flow (hemorrhage)

radiography for rhinologic and sinus

show fractures or occluded sinuses, sinus series (waters view, caldwell view, later view, and submental view)

CT for rhinologic and sinus

makes a clear definition between bony and soft tissue

NSR

nasal septal reconstruction

SMR

septoplasty or submucous resection

submucosal resection (septoplasty resection)

excision and resection of nasal cartilage to adress deviated septums or enlarged turbinates that cause obstructed airway, sinus infections, and nose bleeds, restores adequate airway

what topical is used for SMR?

cocaine or neosynephrine

what is an important step to remember for SMR?

save cartilage in saline-moistened raytec in a safe place (do not throw away)

repair of nasal fracture

simple fractures can be managed with topical and local anesthesia, general used for anxious patients, bones are elevated and molded into place by external manipulation

treatment of epistaxis

treated in surgery when emergency room treatment has failed, vessels coagulated and nose packed (ethmoid, carotid, or maxillary artery must be ligated), can use Foley catheter for pressure

caldwell-lac procedure

naso-antral “window” is cut out of maxillary bone (above canine tooth) to remove sinus mucosa and/or polyps

what is the goal of caldwell-lac procedure?

clear away scar tissue formed from chronic infection and sinusitis, to establish better drainage

sinus endoscopy (functional endoscopic sinus surgery FESS)

excision of polyps, inflamed and/or anatomic defects of the sinuses using an endoscope

what is the goal of sinus endoscopy?

to re-establish adequate ventilation by clearing the sinuses, patients often have had recurrent sinus infections or allergies

balloon sinuplasty

balloon catheter placed into affected sinus, this widens the sinus by restructuring the bone and tissue around it, allows for improved drainage of mucus and better airflow

ethmoidectomy

removal of diseased portion of middle turbinate, ethmoid cells and diseased tissue in nasal fossa, done to treat chronic inflammatory sinus disease or polyps caused by allergies

sphenoidectomy

creation of an opening into 1 or both sphenoidal sinuses, often done in conjunction with a ethmoidectomy

nasal polypectomy

removal of polyps from the nasal cavity, they are benign, grape like clusters or mucous membrane and connective tissue, most commonly caused by allergic rhinitis (micro debrieder often used)

turbinectomy

can be anterior inferior, anterior middle, and inferior, removal of hypertrophied turbinates, uses turbinate cautery and micro debrieder

valve reconstruction

nasal valves are the narrowest point in the nasal passageway, it can cause obstruction(nasal valve collapse), several techniques which use a cartilage graft to support the nasal valve structure

robotics for nasal surgery

performs tissue removal, polyp excision, or sinus drainage, uses flexible endoscopes, allows for greater flexibility and access into harder to reach areas within the sinuses