Ear Instrument Test
Ear - Otology - Surgical Instruments Course, Kevin Kavanagh

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Catherine Kavanagh, 
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A tympanoplasty is the repair of the eardrum or middle ear bones.  This section will present a eardrum repair.       Click on pictures to enlarge !!!

The patient's ear is preped and draped.  The surgeon will inject the post auricular area and ear canal with Xylocaine with Epinephrine, in a syringe with a 27 gauge needle, for hemostasis.  He will then usually use one of two types of surgical approaches.

The first is a post auricular approach where the surgeon performs surgery through an incision behind the ear.  In this approach, the periosteum over the anterior mastoid tip is reflected anteriorly using a periosteal elevator (pictures below) until the ear canal skin is identified. 


Using gentle traction, the ear canal skin is elevated off the posterior ear canal then cut across allowing the surgeon to enter the canal.  The incision is then retracted and held open using the forceps shown on the right.   The retractor has two distinct arms.  The arm with the three prongs, grasps the posterior part of the wound and the arm with the flat projection, pushes the ear canal skin forward.  This flat projection has three small sharp barbs which keep it from slipping. 

The second type of surgical approach is through the ear canal.  This is called an end-aural approach.  A small posterior-superior post-auricular (above and behind the ear) incision is still used to harvest the fascia used to repair the drum.  Ear speculums are then used to widen the ear canal and provide exposure.  The surgeon's hand or a speculum holder are used to keep the speculums in position.  Ear speculums may be round or slightly oval and come in a variety of sizes.  Many are ebonized or blackened to reduce light reflection from the operative microscope.


Through the post auricular incision a piece of temporalis fascia is harvested to be used to close the eardrum perforation.  The fascia is usually pressed and allowed to dry.  This facilitates placement and positioning in the middle ear.  Some surgeons use sterile tongue blades clamped by a cocker to press the fascia.  Other surgeons will use a fascial press -- shown in the picture on the right.

The scalp does not stretch, thus ,an assistant should not try to retract the scalp but to pull the scalp up creating a surgical access hole to the temporalis fascia.  The surgeon will then work through this hole to harvest the fascia.  Since he may have to cut the fascia, which is deep in the hole, a pair of  curved scissor are very useful. 


The next step is to rim the perforation.  A long straight sharp pick or needle is used to cut a circular incision around the margins of the perforation.  This is called "freshening the margins of the perforation".   A Rosen Needle (pictured on the right) and cup forceps are used to accomplish this step.


 The pictures on the left show a cup forceps. 

The next step is to elevate the ear canal skin flap.  A flap knife is used for this purpose.  Two of the most common knifes are a round knife and a duckbill knife.  Both terms describe the shape of the flap knife. 

A Rosen Round Knife is shown in the pictures on the right


An Austin Duckbill Knife is shown in the pictures on the right.

Some surgeons prefer to cut the ear canal skin flap sharply using a beaver blade or sickle knife - see right picture.  In my experience this causes excess bleeding with is avoided by using the otologic flap knives.  These knives are duller and crush the blood vessels, reducing their tendency to bleed.

Blood is removed using Baron Suctions in three sizes #3, #5, and #7 French.  A #3 is the smallest suction of the three and the most common size used in surgery.  This is the suction size the surgeon will probably start out with. 


The ear canal flap is elevated down to the eardrum which is attached to the ear canal bone by a small ligament called the "annular ligament".  This ligament can sometimes be hard to elevate.  For this reason special instruments have been devised to elevate the ligament out of its sulcus. 
Annulus elevator called a Gimmick 

Annulus elevator called a Bayonet.


middle ear is then entered and the temporalis is placed in the middle ear with a cup or alligator forceps.  The fascia is then advanced forward using a Derlacki Mobilizer--see picture on the right.  This is an instrument which has a small flat knob at the end.  The knob has several small spins which will grab the fascia and the knob keeps the instrument from penetrating thought the fascia. 

After the fascia is advanced into position, gel foam is placed between it and the
middle ear mucosa to hold it in position.  The gel foam should be pressed and precut.  A single hole punch is useful to make standard size pieces.  The round circles can then be cut into half and quarter sizes.  This should be done BEFORE the surgery begins and BEFORE the surgeon enters the room.  The gel foam is gently grasped using an alligator forceps and advanced using a Derlacki Mobilizer. 
A blunt needle will often not grab the fascia or gel foam and a sharp needle will often perforate and pass through the fascia and gel foam.

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