TYMPANOMASTOIDECTOMY OPERATIVE SAMPLE
DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Bilateral cholesteatoma.
POSTOPERATIVE DIAGNOSIS: Bilateral cholesteatoma.
OPERATION PERFORMED:
1. Right tympanomastoidectomy.
2. Intraoperative facial nerve monitoring, 3-1/2 hours.
3. Examination of left ear under anesthesia.
SURGEON: John Doe, MD
ANESTHESIA: General anesthesia.
INDICATION FOR OPERATION: Bilateral cholesteatoma, presents for right tympanomastoidectomy and procedures described above.
DESCRIPTION OF OPERATION: In supine position, general anesthesia was induced. The patient was intubated oroendotracheally. The left ear was examined with a microscope. There was no cholesteatoma recurrence. In the region of the last surgery, where we had left open the sinus tympani, there was no cholesteatoma recurrence. This area, however, was slightly mucosalized.
The patient was positioned for right ear surgery. Ear canal as well as postauricular region was injected with 1% lidocaine with 1:50,000 epinephrine. The Xomed nerve integrity monitors were used to monitor orbicularis oris and orbicularis oculi muscles and appropriate impedance levels obtained. The patient was positioned, prepped and draped. A canal incision was made about 2 to 3 mm lateral to the annulus, nearly circumferentially.
We should make note that upon examining the ear with a microscope, prior to prepping and draping, the entire mesotympanum was full of yellowish-green pus, sent for aerobic culture with sensitivity. This was then aspirated demonstrating cholesteatoma filling the entire upper mesotympanum extending into the attic. The entire tympanic membrane was retracted, acting as a cholesteatoma sac. There was squamous cholesteatoma debris noted medial to the manubrium. The posterior half of the mesotympanum was either mucosa or perforation. In either case, it was full of granulations.
After canal incision was made, postauricular incision was made, 0.5 cm, in the posterior sulcus. Auricle reflected anteriorly. A posteriorly-based mucoperiosteal flap was created just posterior to the ear canal. The temporalis muscle was retracted superiorly. A C-shaped incision at the bony-cartilaginous junction was made with cautery to reflect the ear canal anteriorly, and canal was dissected medially down to the canal incision previously made.
The pinna was retracted anteriorly with a Penrose and self-retaining retractor. The remaining tympanomeatal flap was now dissected down to the annulus. The annulus was dissected out from the posterior notch of Rivinus to about the 5 o’clock position. The chorda tympani nerve at this point was identified. We were not able to preserve as it was enveloped in the cholesteatoma sac. It was preserved, however, at this point.
There was an erosion of the scutum with cholesteatoma debris extending into the attic. Review of CT shows erosion of the distal incus and, indeed, careful exploration at this point of the posterosuperior quadrant showed no long process of the incus nor any stapes superstructure. There was cholesteatoma sac extending down to the oval window niche.
Some of the posterior and superior bony canal was drilled with constant irrigation and coarse diamond bur, and then, using 2 mm drill, atticotomy was performed, removing at this point about half of the scutum. There was cholesteatoma debris medial to the head of the malleus and incus. The neck of the malleus was cut with malleus nipper and first the osteitic remaining part of the body and short process of the incus was removed. The long process was not present, it had been resorbed, and the osteitic head of the malleus was removed. The attic was full of granulation and some degree of cholesteatoma. Completion of the atticotomy was performed, bringing the scutum nearly flush with the tegmen as well as opening anterior epitympanic angle, taking out all of the retracted sac/cholesteatoma and granulations in this region.
The cholesteatoma sac was followed posteriorly by using drill and curette. The sac extended just a bit into the aditus and beyond that was just some granulation tissue. This was all reflected anteriorly, therefore allowing complete resection of the epitympanic and aditus sac.
We now worked inferiorly. The chorda tympani nerve had been sacrificed at this point. We continued to drill back some of the posterosuperior bony canal. We now explored the posterosuperior quadrant in more detail. There was no stapes superstructure. The cholesteatoma sac had been reflected away from the oval window niche, which, in large part, especially posteriorly, was full of granulations. We did not attempt to further remove this. The facial nerve was identified. The proximal portion of the second genu and the second genu itself were dehiscent, stimulating at 0.4 milliamps. Anterior to this, above the tensor tympani, prior to the ganglion, we were able to stimulate through bone at between 0.6 and 0.8.
Tensor tympani tendon was cut. The remainder of the retracted cholesteatoma-involved tympanic membrane was dissected free of the mesotympanum. Completion of the circumferential canal incision was made, and circumferentially, the tympanomeatal flap was dissected down to annulus. The annulus was removed, and the entire tympanic membrane with cholesteatoma was removed. It appeared at this point that we indeed did resect the cholesteatoma completely.
We were also able to visualize completely the opening of the eustachian tube. Mucosa in the eustachian tube appeared normal. A temporalis fascia graft about 1.5 cm x 1.5 cm was harvested and pressed. A 0.041 thick piece of reinforced Silastic was carved to hopefully maintain the middle ear space with one piece of it extending into the eustachian tube, the other piece extending over the oval window niche and inferiorly, a bit into the sinus tympani.
A piece of chondral cartilage was harvested to fill the posterosuperior epitympanum and into the aditus so that neotympanic membrane would hopefully not retract back into that region. The temporalis fascia graft was placed, covering the entire middle ear cavity, extending up to the tegmen, up the remnant posterosuperior canal, completely covering the cartilage graft and also extending down onto the inferior canal and anterior canal.
A Pope Otowick was placed medially to keep the graft in position. Auricle was replaced back into its natural position. The mucoperiosteal flap was closed with interrupted 3-0 Vicryl. The postauricular incision and dermis was closed with interrupted 3-0 Vicryl and skin edges closed with running 6-0 fast-absorbing gut.
Now, examination through the ear canal confirmed proper placement of the Pope Otowick. The lateral ear canal skin was replaced behind the Pope Otowick and two additional Otowicks were placed in the ear canal, expanded with Floxin otic. Bacitracin-coated cotton ball applied at the meatus as well as bacitracin on the postauricular incision and a mastoid dressing was applied.
At this point, the tympanomastoidectomy and related procedures were concluded. The patient was awakened from general anesthesia, extubated, and brought to the recovery room breathing spontaneously, in stable condition. There were no intraoperative complications. Estimated blood loss was minimal. Specimens were middle ear pus for aerobic culture and the soft tissue and ossicles for pathologic interpretation.
Intraoperative findings were reviewed. Osteitic malleus, long process incus erosion with osteitic remnant incus, no stapes superstructure, Silastic placed in the middle ear to hopefully allow for aerated middle ear. The patient will need a second-look operation in 9 to 12 months to assess for recurrent cholesteatoma.
The patient was discharged on Levaquin, and he was also given an intraoperative dose of Levaquin, as well as discharged on Tylenol No. 3.
