UC SF. Safe Surgery Rule #1. Cholesteatoma. It s hard to have a surgical complication when you are not operating

Transcription

1 UC SF Cholesteatoma Chronic Ear Surgery: Staying Out of Trouble! Lawrence R. Lustig, MD Department of Oto-HNS University of California San Francisco Ligaments and folds Spaces NU Epitympanic Cholesteatoma Mesotympanic Cholesteatoma My Top 10 Safe Ear Surgery Recommendations Safe Surgery Rule #1 It s hard to have a surgical complication when you are not operating

2 You Can Follow a Retraction Pocket With: When is a retraction pocket a cholesteatoma? Otomicroscopy Serial Audiograms CT Otoendoscopy Retained keratin inaccessible to cleaning Recurrent granulation tissue and otorrhea Evidence of bone destruction on PE or CT NU Diffusion Echo Planar-MRI for following Chole recurrence vs Granulation Tissue 90% Sensivity 60% Specificity Safe Surgery Rule #2 Know Your Adversary Diffusion-weighted imaging Toyoma et al, 1998

3 Have the following IN the OR with you CT Scan of Temporal Bone Audiogram Conductive hearing loss; SNHL possible CT Scan of Temporal Bone Useful in defining extent of cholesteatoma, ossicular erosion, FN anatomy, inner ear fistula CT Scan: Fistula CT Scan: Tegmen Abnormalities

4 Safe Surgery Rule #3 Surgical Options Know How To Get Where You re Going TRANSCANAL Canal Wall Up Canal Wall Down Tympanoplasty Tympanotomy alone Atticotomy Tympanomastoidectomy Facial recess approach Atticotomy Modified Radical Mastoidectomy Radical Mastoidectomy Congenital Cholesteatoma Congenital Cholesteatoma

5 Safe Surgery Rule #4 Safe Surgical Techniques: Mastoidectomy Define: Tegmen, Sigmoid Sinus, LSCC, FN Exposure Exposure Exposure Thin the Posterior Canal Wall Drill Parallel Descending FN w/ 3 mm diamond burr using constant suction/irrigation See Through Bone Cool the VII n. Remove Debris and Improve Visibility Surgical Issues: Exposure Remove incus in mastoid If intact, amputate with laser or cut IS joint Resect head of malleus (malleus nippers) Open up Facial recess widely Facial Recess Widely Opened

6 Safe Surgery Rule #5 Keep Your Friends Close and Your Enemies Closer Sun-Tzu NU Avoiding Facial Nerve Palsy During Ear Surgery Should FN Monitoring be used routinely in Mastoid Surgery? Tool to reliably identify facial nerve Assess the immediate risk of injury Proceed with increased safety YES

7 Tympanic Segment Risks High Risk during Surgery for Cholesteatoma Disease: Chole growth often involves the Tympanic FN Surgery: Often need to dissect matrix off Tympanic FN Anatomy: Bony overlying Tympanic FN is THIN! Normal Exposed Areas of FN commonly eroded by cholesteatoma Exposed Danger

8 Key Landmarks for the Mastoid Segment Superiorly: HSCC Inferiorly: Digastric Ridge Stylomastoid Foramen Medially: PSCC Jugular Bulb Laterally: Chorda Tympani I Can t Find It!!! If It is Difficult to Find CN VII: Identify the Digastric Ridge - trace to SMF Identify the Chorda Tympani and trace it to FN Short Process of Incus Points to the Facial Recess Just above the Oval Window Just superior to cochleariform process Just anterior to horizontal SCC Safe Surgery Rule #6 Be Nice to the Ossicles Safe Surgery Rule #6 How to Avoiding Injury to the Stapes covered by Chole

9 Laser Removal of Matrix Matrix over Stapes Argon laser with Otoprobe Dissection along ossicles; reducing granulation tissue Excise matrix adjacent to stapes Laser or joint knife Matrix through Stapes Safe Surgery Rule #7 Always Use Protection Remove suprastructure with laser Dissect with joint knife

10 Safe Surgery Rule #7 Ossicular Reconstruction Options ALWAYS use a graft between an ossicular prosthesis and the drum TOP to cartilage/tm TORP to Malleus Attic Reconstruction Cartilage Cutters to thin cartilage Cartilage Reconstruction Crucial for preventing recurrence

11 Safe Surgery Rule #8 It s Better the 2nd Time Around Staging: Children Disease in sinus tympani Adult & Pediatric Cholesteatoma Common Sites of Residual Disease Smyth 1976 (primarily CWU) Recurrence in children 24% Recurrence in adults 6% Oval Window Facial Recess Sinus Tympani Sheehy patients with 181 children Overall residual rate 18.9% Residual rate in children 36% Not The Mastoid

12 Risk Factors for Recurrence Risk Factors for Residual and Recurrent Disease Gristwood and Venables 1990: 251 patients Young age & ossicular erosion common factors Rosenfeld 1992: regression analysis CWU vs CWD no difference Ossicular erosion true predictor with relative risk of depending on the number of ossicles eroded Stern and Fazekas (1992) 53 children over 10 yrs Primary acquired=cwu Secondary acquired CWU or CWD (most) FR ST Disease in sinus tympani predictive of failure (p < 0.05) Safe Surgery Rule #9 A Bowl is better than a Vase Bad Good

13 CWD Mastoidectomy 1. Smooth out remnant Anterior canal wall 2. Open up anterior sulcus 3. Smooth transition between canal and mastoid 4. Lower Facial Ridge through mastoid tip Remove tip Lower facial ridge Keep FN bony covered 7 Can further reduce mastoid cavity with Palva flap to sino-dural angle 5. Take down mastoid tip to digastric ridge, carry forward 6 Posterior-lateral-inferior mastoid limit is now the sigmoid sinus Safe Surgery Rule #10 Avoid the Ship in Bottle

14

15 Meatal Tacking Sutures NU Adaptic gauze roll meatal plug w/ antibiotic ointment Or Trimmed Kennedy Sinus Packs Modified Radical Mastoid Cavity A well formed meatus

16