External and Middle Ear Surgery

What is a Pinna Plasty?

A pinna plasty, also known as otoplasty, is a surgical procedure performed to reshape or correct abnormalities of the external ear, specifically the pinna (the visible, external part of the ear). It is typically done to address prominent or protruding ears, often referred to as "bat ears." The procedure aims to reposition the ears closer to the side of the head for a more natural appearance.

Indications

Indications for pinna plasty may include:

• Prominent Ears: When ears protrude prominently from the head, it can cause psychological distress, especially in children who may be teased or bullied at school. Correcting this can boost self-esteem and confidence.
• Age: Surgical correction can be carried out whenever the patient wishes but is generally not recommended before the age of about six because the cartilage in the ear is still developing. Waiting until this stage ensures a more stable and lasting result.

Before a Pinna Plasty:

Before the operation, medical photographs will be taken which will be used to plan the surgery.

Pinna Plasty – The Operation:

Pinna plasty is usually carried out under a general anaesthetic.

The cartilage is exposed from behind the ear, and the deficient fold in the cartilage is reconstructed.

The cartilage may be re-shaped, folded, or part of it may be removed.

Stitches through the cartilage are usually required to hold the ear in its new position.

The skin is then closed with either dissolvable sutures or biological skin glue.

A tight dressing or bandage is placed around the head to maintain pressure on both ears.

×

×

Meatoplasty surgery is used to widen the entrance to the external ear canal.

Indications

Meatoplasty surgery is often the only remedy for patients whose meatus is too small and is restricting the normal flow of earwax.

As a result, earwax and dead skin cells build up, leading to frequent infection and a temporary reduction in hearing ability.

Meatoplasty surgery can be performed under either a local or general anesthetic.

A section of cartilage is removed from around the ear canal opening while preserving the overlying skin.

The skin is then re-stitched to the underlying tissue to open up the canal.

×

×

Myringotomy, from Latin myringa "eardrum," is a surgical procedure in which a tiny incision is created in the eardrum to relieve pressure caused by excessive build-up of fluid or to drain pus from the middle ear.

Procedure Details

A tympanostomy tube is inserted into the eardrum to keep the middle ear aerated for a prolonged time and to prevent re-accumulation of fluid.

Without the insertion of a tube, the incision usually heals spontaneously in two to three weeks.

Depending on the type, the tube is either naturally extruded in 6 to 12 months or removed during a minor procedure.

Indications

Those requiring myringotomy usually have an obstructed or dysfunctional Eustachian tube that is unable to perform drainage or ventilation in its usual fashion.

Before the invention of antibiotics, myringotomy without tube placement was also used as a major treatment of severe acute otitis media (middle ear infection).

There are numerous indications for tympanostomy in the pediatric age group, with the most frequent including:

• Chronic otitis media with effusion (OME) unresponsive to antibiotics
• Recurrent otitis media

Adult indications differ somewhat and include:

• Eustachian tube dysfunction with recurrent signs and symptoms, including fluctuating hearing loss, vertigo, tinnitus, and a severe retraction pocket in the tympanic membrane
• Recurrent episodes of barotrauma, especially with flying, diving, or hyperbaric chamber treatment, may merit consideration.

×

×

×

Myringotomy Instruments

×

Myringotomy Instruments

A Mastoidectomy is a procedure performed to remove the mastoid air cells. This can be done as part of treatment for mastoiditis, chronic suppurative otitis media, or Cholesteatoma.

In addition, it is sometimes performed as part of other procedures like cochlear implant surgery or for access to the middle ear. There are classically 5 different types of Mastoidectomy:

1. Radical Mastoidectomy: Removal of the posterior and superior canal wall, meatoplasty, and exteriorization of the middle ear.
2. Canal Wall Down Mastoidectomy: Removal of the posterior and superior canal wall with meatoplasty. The tympanic membrane is left in place.
3. Canal Wall Up Mastoidectomy: The posterior and superior canal wall are kept intact, and a facial recess approach is taken.
4. Cortical Mastoidectomy (Schwartze Procedure): Removal of mastoid air cells is undertaken without affecting the middle ear. This is typically done for mastoiditis.
5. Modified Radical Mastoidectomy: This is somewhat confusing because it's typically described as a radical mastoidectomy while maintaining the posterior and superior canal wall, resembling the Canal Wall Up Mastoidectomy.

Indications for Mastoidectomy

• A mastoidectomy is often an initial step in the removal of lateral skull base neoplasms, including vestibular schwannomas, meningiomas, temporal bone paragangliomas (glomus tumors), and epidermoids.
• Complications of otitis media, including intratemporal or intracranial suppuration and lateral venous sinus thrombosis, often necessitate a mastoidectomy.

Contraindications for Mastoidectomy

• Patients with medical conditions precluding general anesthesia.
• Patients with a poorly pneumatized mastoid (sclerotic) may make surgery more complicated, as certain anatomic landmarks may be more challenging to identify (otic capsule, facial nerve).
• Surgeons should proceed with caution in patients with anterior displacement of the sigmoid sinus and a low mastoid or middle ear tegmen (roof). These anatomic variants can be identified preoperatively with a temporal bone CT scan.

×

×

×

×

×

Tympanoplasty is the surgical operation performed for the reconstruction of the eardrum (tympanic membrane) and/or the small bones of the middle ear (ossicles).

Tympanoplasty is classified into five different types, originally described by Horst Ludwig Wullstein (1906–1987) in 1956:

1. Type 1: Involves repair of the tympanic membrane alone when the middle ear is normal. A type 1 tympanoplasty is synonymous with myringoplasty.
2. Type 2: Involves repair of the tympanic membrane and middle ear despite slight defects in the middle ear ossicles.
3. Type 3: Involves removal of ossicles and epitympanum when there are large defects of the malleus and incus. The tympanic membrane is repaired and directly connected to the head of the stapes.
4. Type 4: Describes a repair when the stapes footplate is movable, but the crura are missing. The resulting middle ear will only consist of the Eustachian tube and hypotympanum.
5. Type 5: Involves a repair of a fixed stapes footplate.

The term 'myringoplasty' refers to repair of the tympanic membrane alone.

There are several options for treating a perforated eardrum. If the perforation is from recent trauma, many ear, nose, and throat specialists will elect to watch and see if it heals on its own. After that, surgery may be considered.

Myringoplasty is the closure of the perforation of pars tensa of the tympanic membrane. When myringoplasty is combined with ossicular reconstruction, it is called tympanoplasty.

The operation is performed with the patient supine and face turned to one side.

The graft material most commonly used for the surgery is temporalis fascia. The tragal cartilage and tragal perichondrium are also used as the graft by some surgeons.

Myringoplasty restores hearing loss in certain cases of tinnitus.

The chances of re-infection and persistent discharge are less after surgery. Myringoplasty should not be performed if there is active discharge from the middle ear, or if the patient has uncontrolled nasal allergy, or when the other ear is dead, and in children less than 3 years of age.

Myringoplasty is often done under general anesthesia, but it can be done under local anesthesia also.

Technique of Surgery - Underlay Technique

The temporalis fascia is grafted. An incision is made along the edge of the perforation and a ring of epithelium is removed.

A strip of mucosal layer is removed from the inner side of the perforation.

The middle ear is packed with gelfoam soaked with an antibiotic.

The edges of the graft should extend under the margins of the perforation, and a small part should also extend over the posterior canal wall.

The tympanomeatal flap is then replaced.

Technique of Surgery - Overlay Technique

The temporal fascia is harvested.

An incision is made to raise medial meatal skin with tympanic membrane epithelium.

The graft is placed on the outer surface of the tympanic membrane and a slit is made to tuck it under the handle of malleus.

The ear is packed with gelfoam and antibiotics, and the incision is closed.

Finally, a mastoid dressing is performed.

Tympanoplasty can be performed through the ear canal (trascanal approach), through an incision in the ear (endaural approach), or through an incision behind the ear (postauricular approach).

A graft may be taken to reconstruct the tympanic membrane. Common graft sites include the temporalis fascia and the tragus.

The goal of this surgical procedure is not only to close the perforation but also to improve hearing.