gopen mastoid surgery review

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  • CHPT 126
    Cranial-Base Surgery

    See quiz handout
  • CHPT 127
    Surgical Techniques to Enhance Prosthetic Rehabilitation

  • Mastoid Surgery

    Quinton Gopen, M.D.

    UCLA Medical Center

    April 25th, 2012

  • Mastoidectomy

    Canal Wall UpFacial Recess approachAtticotomyCanal Wall Down
  • Canal Wall Up

    Skin incisionFascia harvestPeriosteal incisionBone removalSequential landmarksIdentify TegmenMastoid antrumLateral semicircular canalOptionalIncusFacial NerveSigmoid sinus
  • 39.psd
  • 40.psd
  • 41.psd
  • 42.psd
  • 43.psd
  • 44.psd
  • 45.psd
  • Facial Recess

    Perform a canal wall up mastoidectomyThin the posterior canal wall

    Boundaries:

    Superior: incus or incus buttressPosterior: facial nerveAnterior: bony ear canal, chordae tympaniInferior: bifrication of facial nerve and chordae tympani
  • Facial Recess

    38.psd
  • Atticotomy

    Only indicated for disease limited to the attic and middle ear spaceDo not use for posterior extension into the mastoid/antrum!
  • 65.psd
  • Canal Wall Down

    64.psd
  • Canal Wall Down

    Keys:Take canal wall down to level of facial nerve(avoid high facial ridge)Wide meatoplasty For postoperative mastoid bowl cleaning and aerationLine mastoid cavitySplit thickness skin graft or fasciaAvoids excessive granulation tissue and drainageSaucerize and remove air cells thoroughlyNo rough edges smooth cavityRemove mastoid tipHelps to avoid difficult to reach inferior extent of cavity
  • Labyrinthine Fistula

    61.psd62.psd
  • Controversies

    CWU vs CWDMandatory CWDUnreconstructable EAC defectLabyrinthine fistulaPoor healthPoor compliance2nd look procedureRecividism or recurrenceMiddle ear endoscopyMastoid OblitterationPediatrics vs. Adult
  • Controversies

    Pediatric Cholesteatoma more aggressive than adult?DeCorso 2006 Review of 60 children versus 308 adults with acquired cholesteatomasAll underwent CWD T/MFound higher incidence of incus and malleus erosions, more advanced stage, and higher incidence of recurrenceGenerally accepted that more extensive disease in children compared to adults and that residual and recurrent disease found at higher rates
  • Board Review

  • Board Review

    Where is the most likely area a fistula will form when cholesteatoma is present?Choices: CochleaPosterior SSCLateral SSCSuperior SSC
  • Board Review

    A surgeon performing a cholesteatoma excision via a canal wall up mastoidectomy calls you. The surgeon states that the cholesteatoma was not difficult to remove and that a facial nerve monitor was in use and did not demonstrate any aberrant responses. The child awoke with facial weakness per his report. He states that the eye closure is good but there is no lip movement upon maximal effort. He calls you for your management?
  • Board Review

    Lesion within petrous apex that is hyperintense on T1 and T2 MRI sequences that does not enhance with gadolinium?Choices:Normal bone marrowCholesteatomaCholesterol granulomaGlomus tumorAcoustic neuroma
  • Board Review

    Lesion within petrous apex that is hypointense on T1, hyperintense on T2 and does not enhance with gadoliniumChoices:Normal bone marrowCholesteatomaCholesterol granulomaGlomus tumorAcoustic neuroma
  • Board Review

    While in surgery, the surgeon notes that the cog has been eroded by cholesteatoma. What is the most likely other structure to be affected?Choiceslateral semicircular canalvertical facial nerve segmenttympanic facial nerve segmentintracannalicular facial nerve segmentJugular bulb
  • Cog and Supratubal Recess
    AJNR 18: 1109-1114 1997

  • Board Review

    What is a boundary of the sinus tympani?Choices: chorda tympanicochleariform processpyramidal eminencetensor tympanitympanic membrane
  • Board Review

    Discussion:

    The sinus tympani is a depression along the posteromedial wall of the middle ear cavity. It lies between the bony labyrinth medially and the pyramidal eminence and facial nerve laterally - can be seen on the following histologic section

    answer: pyramidal eminence

  • Board Review

    Patient has a tympanic retraction pocket extending into the sinus tympani. The retraction pocket is inadvertently transected during middle ear exploration. The tympanic membrane defect was repaired with a graft. Which postoperative complication is he at greatest risk for?Choices: cholesteatoma of the mesotympanum medial to the incuscholesteatoma of the epitympanum lateral to the incustympanic membrane perforationdamage to the lateral semicircular canalperilymphatic fistula at the oval window
  • Board Review

    Discussion:

    The patient is at risk for cholesteatoma given the retained pocket left in the sinus tympani. Since the sinus tympani is NOT in the epitympanum but rather lives in the mesotympanum as a depression along the medial wall along with the round window niche (inferior) and the oval window niche (superior) I would expect the cholesteatoma to be in the mesotympanum medial to the incus

    answer: cholesteatoma of the mesotympanum medial to the incus

    Anatomy of the Temporal Bone

    With Surgical Implications

    (Gulya/Schuknecht)

  • Board Review

    Difficult removal of cholesteatoma but surgeon thinks nerve was not injured. Postoperatively patient has complete facial nerve paralysis persisting for one week. On POD #7 stimulation of facial nerve on that side results in brisk movement of face. How to manage this patient?Choices:middle ear exploration with facial nerve decompressionObservationMRI scanMiddle fossa approach with facial nerve decompressionTransmastoid approach with facial nerve decompression
  • Board Review

    Discussion:

    Within the first 3 days after onset of complete paralysis, the results of NET, MST, and ENoG yield little useful information as Wallerian degeneration distal to the stimulation area has not yet occurred and the results always indicate incomplete degeneration. Because of this limitation, the prognosis cannot be established until the sixth or seventh day after paralysis by NET, MST, or ENoG. In this case we are 7 days out, the nerve still stimulates implying that it is intact - so I would argue that we leave it alone!

    answer: observation only