Manual of Otologic Surgery

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Preface

The gold standard of otological training remains the use of cadaver temporal bones
to generate the highest-fidelity simulation model in terms both of visual and tactile
realism. Generations of surgeons have relied on this type of training to gain ana-
tomical knowledge and confidence. Many experienced otologists routinely spend
time in temporal bone labs to refresh their skills and practice uncommon approaches.
This manual is written for trainees in Otolaryngology, novice surgeons, and
those interested in concise descriptions of modern temporal bone dissections. It is
not meant to serve as a surgical textbook but a compendium reference source that
provides

• Step-by-step introduction to modern temporal bone procedures

• Real-life pictures as seen in the OR without any post processing
• Tips and pearls for surgical dissection in the OR

We would like to acknowledge Prof. Tschabitscher, Prof. Gstöttner, Dr. Riss, and
Dr. Honeder for their collaboration and help in the preparation of this manuscript.

Vienna, Austria Christoph Arnoldner

Toronto, ON, Canada Vincent Y.W. Lin
Joseph M. Chen

v
Contents

1 General Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2 Cortical Mastoidectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
3 Facial Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
4 Facial Recess (Posterior Tympanotomy or “Wullstein Window”) . . 19
5 Round Window Exposure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
6 Alternative Approaches to the Cochlea . . . . . . . . . . . . . . . . . . . . . . . . 31
Scala Vestibuli Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Middle/Apical Turn Cochleostomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Middle Fossa Approach to the Cochlea . . . . . . . . . . . . . . . . . . . . . . . . . . 34
7 Unroofing the Epitympanum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
8 Canal Wall Down (Radical Cavity) . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
9 Skeletonizing the Facial Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
10 Endolymphatic Sac Dissection (Retro-/Infralabyrinthine) . . . . . . . . 41
11 Labyrinthectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
12 Internal Auditory Canal (IAC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
13 Middle Fossa Approach (Anterior Transpetrosal/Subtemporal
Approach) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67

vii
General Considerations
1

The thorough knowledge of the complex anatomy of the

temporal bone builds the firm basis for ear surgery. Even
for experienced surgeons, reinforcement of their skills by
training on the cadaver is of tremendous importance.
Temporal bone surgery is based upon a clear under-
standing of relative landmarks in a three-dimensional con-
struct, while absolute measurements are meaningless.
A lateral to medial approach in the gradual identification
of key landmarks is the essence of a safe and efficient tech-
nique. Follow the order of uncovering landmarks described
in this manual; avoid locating a deeper structure (e.g., the
facial nerve) prior to the identification of important refer-
ence points (e.g., Incus and lateral semicircular canal).
The typical surgical setup is shown in Fig. 1.1. The sur-
geon should be seated in a comfortable chair at a comfort-
able working distance from the table.
The typical setup includes the following:

• High-speed otologic drill

• Microscope with eyepiece for observers
• Irrigation either included in the drill system or manu-
ally with bulb or syringe
• Bonesaw to trim the bone to fit in the dissection bowl
• Dissection bowl/temporal bone holder

Electronic supplementary material Supplementary material is

available in the online version of this chapter at 10.1007/978-3-7091-
1490-2_1. Videos can also be accessed at http://www.springerimages.
com/videos/978-3-7091-1489-6.

© Springer-Verlag Wien 2015 1

C. Arnoldner et al., Manual of Otologic Surgery, DOI 10.1007/978-3-7091-1490-2_1
2 1 General Considerations

Fig. 1.1 Typical surgical setup in temporal bone lab

• Scalpel
• Periosteum elevator
• Fraser and otologic suctions
• Round knife
• Rosen needle
• Annulus elevator
• Alligator forceps
• Middle ear scissors

Some basic principles of ear surgery apply to all steps

of the procedure and should always be memorized:

• Use a firm pencil grip when holding the burr (Fig. 1.2).
• Use the largest burr possible to reduce the risk of injury
to important structures. The dissection usually starts
with a 5–6-mm cutting burr.
• Run the burr at full speed, usually between 50 and
60 k rpm. This will render the drill more stable and
reduce chatter and digging.
• Use ample irrigation to remove bone dust and optimize
visualization of structures. This will also avoid heat
damage and necrosis to the bone and facial nerve.
1 General Considerations 3

Fig. 1.2 A firm pencil grip, ample irrigation, and a drill run at full speed are the fundaments for success-
ful temporal bone dissection

• Drill with ½″ to 1″ right to left strokes.

• Drill “inside out,” meaning from more medial to lateral,
whenever applicable (Fig. 1.3). While drilling, the entire
burr should always be visible to avoid inadvertent injury
to hidden structures such as the sigmoid sinus and dura.
• Saucerize the edges of your dissection. This will not only
provide more light to penetrate deeper into your specimen
but also allow your drill and instruments to come into
your field from the side and not block your visualization.
• Fast hand motion while drilling does not equate a
shorter surgical time! It is important to understand that
efficiency of motion in operating a drill becomes more
and more important as the dissection deepens into the
temporal bone, where there is less room for errors.
When using a large cutting burr in the lateral part of the
temporal bone, reduced drill speed tends to lead to a
skittish and unstable drill. A good rule of thumb for
hand motion and drill speed is “…Slower Hands and
Faster Drill”!
4 1 General Considerations

Fig. 1.3 The direction of drilling should be from more medial to lateral (“inside out”) whenever possible

• Develop the discipline of reducing the amplitude of

hand movements; use of variable pressure and tactile
feedback to advance into the next layer is a technique
that bodes well for more advanced skills acquisition.
Drilling by feel, or the term “spot drilling,” is often used
to describe this technique when very little side-to-side
motion is applied (Videos 1 and 9). The drill should be
running in the forward direction at full speed for most
of the drilling, while reduced speed becomes important
in regions that demand less acoustic trauma or directly
over a vital structure (e.g., footplate, round window
niche, internal auditory canal, etc.). Changing the direc-
tion of the drill (i.e., reverse) is important when you
wish to “drill-away” from an important structure, in a
counterclockwise fashion. An example of this for a
right-handed surgeon is when you approach the inferior
aspect of the left internal auditory canal (IAC).
Cortical Mastoidectomy
2

Locating the mastoid antrum is one of the earliest steps in

Landmarks
the dissection of a temporal bone: • Suprameatal spine
The soft tissue from the external auditory canal (EAC) (spine of Henle)
and the root of the zygoma should be released from the • Root of zygoma
bone by carefully pushing it forward with the use of an • Triangle of attack:
elevator. This helps in identifying the suprameatal spine – Linea temporalis
– EAC
(spine of Henle) and the area behind it, named McEwen’s – Sigmoid sinus
triangle (delineated by the temporal line, the posterosupe-
rior segment of bony external auditory canal, and the line
drawn as a tangent to the EAC).

䉴 This maneuver is important to help estimate the

thickness of the bone of the EAC, which needs to be
thinned out extensively prior to drilling the facial recess
(see Fig. 3.2).

First, identify the three structures that create a triangle

of attack into the mastoid (Fig. 2.1, Video 2). The tracking
of one landmark to the other forms the principle of tempo-
ral bone surgery.
Identifying these reliable landmarks is important
in every case, but especially in cases with poor
pneumatization:

Electronic supplementary material Supplementary material is

available in the online version of this chapter at 10.1007/978-3-7091-
1490-2_2. Videos can also be accessed at http://www.springerimages.
com/videos/978-3-7091-1489-6.

© Springer-Verlag Wien 2015 5

C. Arnoldner et al., Manual of Otologic Surgery, DOI 10.1007/978-3-7091-1490-2_2
6 2 Cortical Mastoidectomy

Fig. 2.1 Triangle of attack (EAC external auditory canal, SH spine of Henle, LT linea temporalis, SS
sigmoid sinus)

• The temporal line (inferior limit of temporalis muscle)

as the approximate landmark of the middle fossa plate
is drilled with a large cutting burr in an anterior to pos-
terior direction. Be aware that the brain often hangs
much lower than this line, especially in a sclerotic bone.
• A second line is drilled parallel and just posterior to the
external auditory canal.
• The third line connects the first two lines and presents the
Landmarks
probable posterior extent of pneumatization at the level of
• Suprameatal spine
(spine of Henle) the sigmoid sinus. The sigmoid sinus can extend forward
• Root of zygoma and be located superficially. Avoid injuring the sigmoid
• Triangle of attack: sinus and check its location on preoperative CT scans.
– Linea temporalis
– EAC 䉴 The burr should be moved in a parallel fashion to the vital
– Sigmoid sinus
structures to be preserved: anterior-posteriorly versus the
middle fossa plate, superior-inferiorly versus the EAC and
superior-lateral to inferio-medial versus the sigmoid sinus
(Fig. 2.2).
2 Cortical Mastoidectomy 7

Fig. 2.2 The burr is moved parallel to vital structures (EAC external auditory canal, LT linea temporalis,
SS sigmoid sinus)

䉴 Take care not to drill deep holes, and try to deepen the cavity
evenly and gradually, with the deepest point of penetration Landmarks
in the direction of the antrum. The edges should always be • Suprameatal spine
(spine of Henle)
rounded for optimal visualization.
• Root of zygoma
䉴 Always use the largest burr possible as this will help to • Triangle of attack:
preserve important structures. – Linea temporalis
– EAC
䉴 Apply frequent and ample irrigation to clear every exposed – Sigmoid sinus
air cell. • Mastoid air cells
• Middle fossa dura
Once the cortex is opened, follow the honeycomb of air • Koerner’s septum
cells (Fig. 2.3) which will lead you to the antrum, found • Antrum
just posterosuperiorly to the external auditory canal.
The segmentation and sequencing of a cortical mastoid-
ectomy is explained in Fig. 2.4. Initially, the middle fossa
plate and sigmoid sinus are developed together to establish
the lateral locations of these structures. Then, the antrum is
entered and the cavity is enlarged posteriorly into the sino-
dural angle. Lastly, perifacial and retrofacial air cells are
developed.
In well-pneumatized bones, Koerner’s septum can be
identified as a solid plate of nonpneumatized bone
8 2 Cortical Mastoidectomy

Fig. 2.3 Gradually remove the mastoid air cells between the middle fossa plate, the external auditory
canal, and the sigmoid sinus. Koerner’s septum can be identified as a solid plate of nonpneumatized bone
(EAC external auditory canal, MF middle fossa, KS Koerner’s septum)

V
III
VI
I

IV
II

Fig. 2.4 Segmentation and sequencing of transmastoid dissection. (I dura middle fossa, II sigmoid sinus,
III antrum, IV sinodural angle, V perifacial air cells, VI retrofacial air cells)
2 Cortical Mastoidectomy 9

Fig. 2.5 Koerner’s septum (petrosquamous suture line) on an axial CT scan of a right temporal bone (KS
Koerner’s septum, V vestibule, H-SCC horizontal semicircular canal, IAC internal auditory canal, BC
basal turn of cochlea)

extending across the entire mastoid cavity (Figs. 2.3 and

2.5). It is a segment of the petrosquamous suture line, rep- Landmarks
• Middle fossa plate
resenting the fusion of the squamous and petrous bones. • EAC
• Sigmoid sinus
䉴 Koerner’s septum can be initially mistaken for the hard • Koerner’s septum
bone of the labyrinth and horizontal semicircular canal by • Antrum
the inexperienced surgeon. These structures, of course, lie • Horizontal semicircular
deep to Koerner’s septum. canal

After penetration of Koerner’s septum in the anterior

superior quadrant of the septum, the true antrum will be
seen as a very large air-containing cavity (Fig. 2.6). The
antrum is a very consistent and important structure that
connects the mastoid air cells with the tympanic cavity.
Since there is no important structure lateral to it, the antrum
serves as one of the most important landmarks in the initial
stage of mastoidectomy.
The middle fossa and sinus plates can be identified by a
change in color (dura: pink, sinus: blue), change in burr
10 2 Cortical Mastoidectomy

Fig. 2.6 The horizontal semicircular canal can be seen in the bottom of the antrum. Note the different
appearance of the bone of the labyrinth as compared to the mastoid bone (EAC external auditory canal,
MF middle fossa, H-SCC horizontal semicircular canal, SS sigmoid sinus)

noise, and (in the OR) increased bleeding from the under-
Landmarks lying structures.
• Middle fossa plate
• EAC
• Sigmoid sinus 䉴 In the sclerotic mastoid, where almost no air cells can
• Koerner’s septum be found, identifying and following the dura and the
• Antrum thinned posterior wall of the EAC is the safest way into
• Horizontal semicircular the antrum.
canal
• Fossa incudis In the bottom of the antrum, the horizontal (lateral)
• Short process of incus
semicircular canal can be easily identified by its appear-
ance as smoothly contoured, compact bone (Fig. 2.6).

䉴 Bone of the compact labyrinth is different in appearance

than the air cells of the mastoid.
2 Cortical Mastoidectomy 11

Fig. 2.7 The short process of the incus (arrow) can be expected behind a thin bony shell (H-SCC hori-
zontal semicircular canal)

The next landmark is the short process of the incus in the

fossa incudis, which will be uncovered by progressive ante-
rior drilling. For this delicate step, the specimen (patient)
should be tilted away from the surgeon and a diamond burr
should be used. Remember that touching the (intact) ossic-
ular chain with a rotating burr can lead to a subluxation of
the chain as well as irreversible inner ear damage.

䉴 Water irrigation into the antrum can help in identifying the

short process of the incus (Figs. 2.7 and 2.8).

䉴 After progressively thinning the bone covering the incus, a

curette can be used to remove the last layer of bone. This Landmarks
is the safest way to preserve the integrity of the ossicular • Antrum
chain. The curette is moved medially to laterally (inside to
• Horizontal semicircular
canal
outside) in a slightly twisting movement. • Fossa incudis
• Short process of incus
Continue carefully drilling and removing the bone with • Head of malleus
the house curette anteriorly until the articulation of the incus • Tympanic segment of
and head of the malleus can be identified (Figs. 2.9 and 2.10). the facial nerve
12 2 Cortical Mastoidectomy

Fig. 2.8 After water irrigation, the short process of the incus can be identified in the fossa incudis
(H-SCC horizontal semicircular canal, I short process of incus)

Fig. 2.9 After careful anterior dissection with a diamond burr and a curette, the articulation between the
incus and malleus can be identified. On the floor, the tympanic segment of the facial nerve can be seen
(HM head of malleus, SM superior ligament of malleus, I short process of incus, FN facial nerve, H-SCC
horizontal semicircular canal)