ENT Department Timisoara

2nd Timisoara International Course on

Middle Ear Surgery with
Temporal Bone Dissection

TEMPORAL BONE
DISSECTION

Dr. Stelian LUPESCU

a. Meatoplasty
General considerations
Meatoplasty is a necessary step in
addition to canalplasty when the
cartilaginous portion of the external
auditory canal (EAC) is too narrow
in relation to its osseous portion.
Lateral stenosis of the EAC is
commonly related to congenital
anomalies, minor malformations,
exostosis and postsurgical scarring. It
may lead to hearing impairment,
excessive accumulation of cerumen,
chronic otitis externa, difficulties in
clinical examination and insufficient
self-cleansing properties of the
external ear following canalplasty.
a. Meatoplasty
The principle of meatoplasty is to remove the obstruction
created by excessive conchal cartilage and bone. The
operation is performed with a microscope.
Skin incision
The first superior skin incision begins at the 12 o‘clock
position between the tragus and the helix, as is the case of
an endaural approach, and is continued down to the level
of the superior edge of the bony external auditory canal.
Skin incision
The second incision is made at 6 o‘clock and continues
through the ring of cartilage forming the inferior
edge of the EAC.
A third, medial skin incision connects both previous
incisions horizontally along the posterior edge of the
EAC.
Elevation of the Laterally Based Skin Flap
The laterally based skin flap is elevated using
tympanoplasty scissors. Care must be taken to keep the
skin intact, particularly when separating it from the thin
but strong attachment to the conchal cartilage.
 Exposure and Excision of Choncal Cartilage

Excess conchal cartilage is exposed and excised and the

soft tissues situated between the excised cartilage and
the underlying bone are also removed.
 Enlargement of the Bony EAC

The posterior wall of the bony EAC is enlarged using

a diamond burr.
Wound closure
Before closing the wound, a relieving incision is made
through the inferior part of the inferior part of the
laterally based meatal skin flap to allow superior
rotation of its upper part.
Wound closure
In this way, the enlarged
superior external auditory
meatus is completely
covered with skin, which is
kept in position with 4-0
Ethibond sutures.
The inferior enlarged
portion of the EAC is left
open and will heal by
secondary intention within
2-3 weeks.
 b. Canalplasty

General Considerations
The goal of any tympanomastoid surgical procedure
should be the circumferential enlargement of the bony
external canal to visualize the entire ring of the
tympanic annulus using one position of the microscope.
 Canalplasty

Periosteal Flap
The outline of the retroauricular periosteal flap is formed
with a knife (no 15 blade) and should be approximately the
size of the index finger. The periosteal flap is elevated from
the bone with a mastoid raspatory.
 Canalplasty

Exposure of the EAC

The posterior limb of the canal incision is performed with a no 15
blade, maintaining a level below the entrance of the bony external
canal. The EAC is then opened and the canal incision is extended
anteriorly to the 2 o‘clock position. The soft tissues are moved
away from the bone using a key raspatory
Meatal Skin Flap
Visualization of the entire tympanic membrane using
one position of the microscope is made possible by
forming a large meatal skin flap that is carefully
dissected out of the canal with its inferiorly based
pedicle left in place. In the clinical setting, the
advantage of this type of flap is that its blood supply is
maintained through its pedicle.
Incisions for the Meatal Skin Flap
The meatal flap is incised using a no 11 blade mounted in a
special rounded scalpel handle. The blade is guided along the
lines shown in the figures. Two incisions are made: the first
spirally ascending from medial to lateral and the second running
medially and circumferentially.
Incisions for the Meatal Skin Flap
The spiral incision starts 2mm lateral to the annulus at 7 o ‘clock (right
temporal bone) and swings up laterally along the anterior canal wall
to meet the previously cut external canal skin at 2 o‘clock. Be aware
that skin incisions in the temporal bone do not bleed and are at times
difficult to visualize. Therefore, it is higly advisable to keep in mind
the track previously used by the tip of the knife and to make the
incision in a step-by-step fashion.
Elevation of the Meatal Skin Flap
The skin is elevated from the bone using a Fisch microraspatory
in the right hand and a microsuction tube in the left hand. The
microsuction tube should have a length of 7 cm to permit the
surgeon‘s left hand to rest comfortably on the head of the patient. The
tip of the microsuction tube holds the skin away. The amount of
negative pressure of the microsuction tube is controlled with the left
index finger.
Elevation of the Meatal Skin Flap
The tip of the microaspatory should always remain in contact
with bone. Small movements separate the meatal skin from the
bony EAC in the vertical and horizontal planes.A small strip of
gauze soaked in saline solution protects the skin during
separation from the bone with the Fisch microraspatory.
Circumferential Skin Incision
Following elevation of the lateral part of the meatal skin flap, the
circumferential incision of the meatal skin is created, beginning
and ending 2 mm lateral to the tympanic annulus at 7 o‘clock
(right ear) or at 5 o‘clock (left ear), at the starting point of the
spiral incision..
Circumferential Skin Incision
The anterior limb of the incision is carried out
using tympanoplasty microscissors (modified Bellucci scissors)
along the edge of the antero-inferior bony overhang of the EAC.
The posterior limb of the incision is initiated by cutting
through the posterior surface of the meatal skin flap with a No.
11 blade mounted to a rounded scalpel knife.
Circumferential Skin Incision
The incision is then continued along the superior canal wall
connecting the anterior and posterior limb with straight
microtympanoplasty scissors.
Elevation of Meatal Skin Flap from the Tympanic Bone
Care is taken at this stage to expose the complete tympanic bone, including its
lateral surface. This requires an extension of the base of the meatal skin flap
from the tympanomastoid suture in the antero-superior direction to include the
posterior and lateral surface of the tympanic bone.
Elevation of Meatal Skin
Flap
Separation of the skin covering
the posterior surface of the
tympanic bone is accomplished
using a Key raspatory. The tip of
the raspatory is moved along the
lateral portion of the anterior
bony canal wall, and then gently
rotated anteriorly to completely
uncover the superior edge of the
tympanic bone.
Elevation of Meatal Skin
Flap
In this way, the lateral surface
of the tympanic bone is
completely exposed from the
tympano-mastoid to the
tympano-squamous suture.
This exposure is a prerequisite
to performing an adequate
circumferential canalplasty.
Canalplasty
Most commonly, viewing is limited
to the antero-inferior portion
of the drum owing to an excess of
tympanic bone. The correct
enlargement of the EAC is obtained
by drilling away the overhanging
bone with sharp and diamond burrs.
Canalplasty
In a narrow EAC, it is difficult to identify the antero-inferior tympanic
annulus, which may be completely covered by bone. In this situation, a
groove (trough) is made in the bony inferior canal wall at 6 o‘clock
until the white line of the tympanic annulus becomes clearly visible.
This technique of the inferior trough was developed to avoid injuring
the facial nerve, jugular bulb or internal carotid artery because these
structures are out of reach if the drilling is performed along the inferior
EAC wall and remains lateral to the tympanic annulus.
Canalplasty
After identification, the tympanic annulus is progressively
exposed as far as the anterior and posterior tympanic spine.
When
all bone overhangs are eliminated, the complete drum can be
viewed without having to readjust the position of the microscope.
Canalplasty
After correct canalplasty, it may becomes necessary to apply
relieving incisions on the medial meatal skin to return it to a
proper position.
Canalplasty