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  • 1.  Eardrum PerforationThis picture shows an eardrum with a large perforation. The patient was a 71 year old male who was working in his yard five years ago and had a stick go into his ear canal. Traumatic perforations of the eardrum usually heal on their own, but this one did not.
  • 2.  Ear Canal InjectionThe ear canal is injected with 1% Xylocaine with epinephrine in four quadrants using a 27 gauge needle. The injection controls bleeding and provides anesthesia. Care must be taken not to inject to fast or the ear canal will blister with will cause bleeding and decreased visualization.
  • 3.  Post-Auricular IncisionA post auricular approach was performed. The mastoid tip is palpated and a scalpel incises down to bone inferiorly (left side of picture). Superiorly, the incision is more superficial so the Temporalis Fascia is not injured. The Posterior Auricular Muscle is shown in the picture on the left.
  • 4.  Exposture of Temporalis FasciaInferiorly (left side of the picture), the incision extends down to the mastoid bone. Superiorly, the scalpel is gently moved horizontally (right to left) to spread and slowly divided the tissue over the Temporalis Muscle's Fascia.
  • 5.  Incision of the Linea TemporalisThe fascia over the Temporalis Muscle is exposed. An incision is made at the lower margin of the Temporalis Muscle (Linea Temporalis). This incision extends through the periosteum of the mastoid bone.
  • 6.  Exposure of Mastoid BoneAn incision is then made through the mastoid periosteum, at a right angle to the Linea Temporalis incision.
  • 7.  Elevation of the Mastoid Bone's PeriosteumA periosteal elevator is used to elevate the periosteum off the anterior mastoid tip. The elevation is from posterior to anterior and will expose the skin of the posterior ear canal.
  • 8.  Posterior Auricular Incision ExposureThe resultant exposure shows the posterior ear canal skin, mastoid bone and Temporalis Muscle Fascia.
  • 9.  Harvesting the Temporalis Fascia GraftUsing a scalpel, an incision is made through the lower board of the Temporalis Fascia.
  • 10.  Harvesting the Temporalis Fascia GraftA Freer Elevator is used to separate the Temporalis Fascia from the underlying Temporalis Muscle.
  • 11.  Harvesting the Temporalis Fascia GraftThe Freer Elevator is used to elevate the Temporalis Fascia off of the Temporalis Muscle.
  • 12.  Harvesting the Temporalis Fascia GraftUsing a pair of scissors the Temporalis Fascia is removed from the Temporalis Muscle.
  • 13.  Trimming the Temporalis Fascia GraftThe Temporalis Fascia is spread onto a tongue blade and excess tissue and fat is gently removed using a pair of scissors.
  • 14.  Pressing the Temporalis Fascia GraftThe graft is compressed between two tongue blades. The tongue blades are secured with pressure using a Rochester Clamp.
  • 15.  Entering the Ear CanalThe ear canal skin is elevated off the posterior canal wall using a Freer Elevator.
  • 16.  Entering the Ear CanalThe posterior ear canal skin is incised with a #15 Bard Parker Blade and the inside of the ear canal is exposed.
  • 17.  Eardrum Perforation Seen Through the Post-Auricular IncisionThe eardrum perforation is exposed through the post-auricular incision. The incision is held open by a self-retaining retractor (SRR).
  • 18.  Rimming the PerforationTo allow healing, the margins of the perforation must be removed. A Rosen Needle is used to place a series of perforations in the tissue next to the margin of the perforation.
  • 19.  Rimming the PerforationA pair of Micro-Cup Forceps is used to remove the tissue along the perforation's rim.
  • 20.  Incision of the Ear Canal SkinA Duckbill Flap Elevator elevates an atticotomy flap. An incision is made extending along the inferior portion of the ear canal skin and connected with the incision used to enter the ear canal.
  • 21.  Elevation of the Posterior Ear Canal SkinThe Duckbill Flap Elevator elevates the skin off the posterior wall.
  • 22.  Entering the Middle EarThe Annular Ligament is elevated and the middle ear is entered. The Long Arm of the Incus, Annular Ligament and Promontory can be seen in the picture.
  • 23.  Insertion on the Temporalis Fascia GraftMicro-Cup Forceps are used to insert the Temporalis Fascia Graft into the middle ear.
  • 24.  Stabilization of the Fascia Graft Using GelfoamUsing a Derlacki Mobilizer, Gelfoam is inserted into the middle ear (between the eardrum and promontory) to hold the Temporalis Fascial Graft against the undersurface of the eardrum.
  • 25.  Closing the Middle EarThe Temporalis Fascial Graft and elevated ear canal skin are laid back onto the posterior canal wall. The perforation is then checked to make sure it has been closed with the Temporalis Fascial Graft.
  • 26.  Placing Gelfoam in the Ear CanalGelfoam is placed over the eardrum and the elevated ear canal skin.
  • 27.  Placing Antibiotic Ointment in the Ear CanalAntibiotic ointment is placed over the Gelfoam and fills the medial portion of the ear canal.
  • 28.  Placing Gauze Packing in the Ear CanalThe lateral portion of the ear canal is packed with 1/4 inch gauze with antibiotic ointment through the external auditory meatus. This prevents the closing of the ear canal during healing.
  • 29.  Closing the Post-Auricular IncisionThe deep fascial tissues in the post-auricular incision are closed using a 3-0 chromic stitch.
  • 30.  Closing the Skin IncisionThe post auricular skin is closed with a 4-0 nylon stitch. A mastoid dressing is then applied.

      

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Last updated 02/23/2014    
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Copyright  2014   Cathy  Kavanagh, MD  All Rights Reserved

 





 
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