Contents

Preface - 8

About the author - 9

Introduction - 10

Historical aspects of otolaryngological surgery - 15

History of mastoid surgery - 20

Role of microdebriders in otolaryngology - 23

Otology - 29

Mastoidectomy an introduction - 29

Tympanomastoidectomy - 46

Approaches & mastoidectomies - 47

Modified radical mastoidectomy - 56

Drilling tips - 60

Canalplasty - 61

Otoendoscopy - 64

Endoscopic myringoplasty - 66

Classic myringoplasty - 72

Tympanoplasty - 74

Grommet insertion - 88

Stapedectomy - 94

Ear lobe repair - 98

Surgical techniques in Otolaryngology

2
Preauricular sinus excision - 104

Labyrinthectomy - 111

Meatoplasty - 116

Retrolabyrinthine approach to petrous apex - 122

Middle cranial fossa approach to petrous apex - 126

Rhinology - 132

History - 132

Antral puncture & Lavage - 138

Maxillectomy - 142

SMR & Septoplasty - 154

Caldwell-Luc Surgery - 160

Endoscopic inferior meatal antrostomy - 168

Vidian neurectomy - 172

Transpalatal vidian neurectomy - 178

Endoscopic posterior nasal neurectomy - 182

Approaches to frontal sinus - 185

Endoscopic frontal sinus surgery - 188

Draf Procedure - 189

Frontal sinus rescue - 196

Sewall-Boyden flap usage in external frontal sinusotomy - 198

Diagnostic nasal endoscopy - 202

Bicoronal approach to frontal sinus - 206

FESS - 209

Anatomy of uncinate process - 210

 Uncinectomy - 212

Maxillary antrostomy - 222

Anterior ethmoidectomy - 222

Posterior ethmoidectomy - 222

External ethmoidectomy - 226

Endoscopic management of fronto ethmoidal mucocele - 228

TESPAL - 230

Endoscopic Transnasal optic nerve decompression - 232

Fracture nasal bones reduction - 238

Classification of fracture zygoma - 248

Zygomatic complex fractures - 253

Blow out fracture of orbit - 255

Surgical approaches to orbit - 262

Use of Foley’s catheter in the management of fracture anterior wall of maxilla - 278

Leefort classification of maxillary fractures - 278

Endoscopic orbital decompression - 284

Endoscopic medial wall decompression - 286

Lateral orbitotomy - 288

Endoscopic DCR - 290

Hadad-Bassagasteguy flap - 304

Endoscopic Hypophysectomy - 306

Management of CSF Rhinorrhoea - 312

Intracranial repair of CSF leak - 317

Extracranial repair of CSF leak - 317

 Bath plug technique for closing CSF leak - 320

Lateral rhinotomy - 322

Surgical approaches to nasopharynx - 324

Maxillary swing approach - 324

Mandibular swing approach - 325

Midfacial degloving approach - 326

Transpalatal approach to nasopharynx - 329

Surgical approaches to anterior skull base - 330

Laryngology - 338

Tonsillectomy - 338

Coblation tonsillectomy - 340

Adenoidectomy - 344

Quinsy drainage - 348

Tongue tie release - 352

Tracheostomy - 354

Types of cricothyroidotomy - 372

Percutaneous cricothyroidotomy - 374

Total laryngectomy - 381

Conservative laryngectomy - 390

Lingual thyroid and its management - 408

Elongated styloid process excision - 418

Classification of neck dissection - 426

Mandibular swing approach - 436

Diagnostic & therapeutic sialendoscopy - 440

 Voice rehabilitation following total laryngectomy - 450

Submandibular salivary gland excision - 471

Kashima surgery - 477

Laryngeal framework surgeries - 484

Relaxation thyroplasty - 496

Equipment used in otolaryngology surgery - 498

Diathermy - 499

Operating microscope - 502

Lasers - 508

Coblation in otolaryngology - 523

Coblation tonsillectomy - 544

Coblation kashima procedure - 552

Endoscopic cordectomy - 558

Role of coblation in benign laryngeal lesions - 566

Coblation lingual tonsillectomy - 573

Coblation in tongue base reduction - 576

Coblation in UPPV - 580

Malignant tumor oropharynx ablation using coblation - 584

Rhinophyma excision using coblation - 588

Coblation in oropharyngeal hemanigoma - 592

Diathermy - 596

Suture materials - 600

 Preface

Otolaryngology is a highly specialized field in Medicine.

The learning curve is also pretty steep. The text books available are found to be woefully inadequate
in imparting practical knowledge as far as operative techniques are concerned. This book has been
authored with the intention of imparting practical knowledge and skills from the field of operative
otolaryngology.
This book contains various topics including basic surgical techniques. The author has ensured that
recent surgical techniques are discussed in a detailed manner. Otolaryngology surgery is very de-
manding and instrument intensive. Major novelties as far as surgical instruments are concerned had
taken place in the field of otolaryngology. These instruments are discussed in detailed manner in
this book.

The topics are organized under the following heads:

Otology
Rhinology
Laryngology

This book will help in training the post graduates not only the basic surgical skills but also in ad-
vanced surgical techniques in otolaryngology.

Surgical techniques in Otolaryngology

8
 About the Author

Professor Dr Balasubramanian Thiagarajan was formerly professor and Head Department of Oto-
laryngology Stanley Medical College, Registrar The Tamilnadu Dr MGR Medical University. He is
a devoted teacher with rich academic experience. He has authored many books in otolaryngology.
He is also running websites for the benefit of students of otolaryngology.
Android apps for the benefit of students have been developed by him.

Websites of the author:

1. www.drtbalu.com
2. www.drtbalu.co.in
3. www.drtbalu.in

Android apps:
1. drtbalu’s ENT (Post graduate resource) can be downloaded from android app store.
2. Imaging in Rhinology
3. ENT Instruments
4. ENT Resources

The author can be contacted at E mail.

Prof Dr Balasubramanian Thiagarajan

 Introduction

Otolaryngology which was one of the sub spe- lentil bean.

cialties of General Surgery became a specialty In the 11th century the Arabian scholar Ibn al
of its own during the early 20th century. This Haitham1 first discovered the ability of a convex
happened because of the fact that otolaryn- lens to produce a magnified image of an object.
gological surgical skills had a steep learning The method of combining lenses to obtain an
curve and an aspiring student needed to spend enlarged image was conceived during the end of
a number of years practicing his / her skills the 16th century.
before they can become a complete otolaryngol- Seneca2 described that a globe of water mag-
ogist. It was the otologist who first paved the nifies letters. He used as reading glass. It was
way for separation of this specialty from general during 16th century that optical instruments
surgery. Surgeons of the 20th century bravely were designed by combining a series of convex
performed otological and laryngeal surgeries lenses. There is a lot of confusion regarding the
under primitive anesthesia with virtually no invention of compound microscope. If only a
antibiotics. Majority of their success could be single lens is used, (as in reading glass, or the
attributed to the excellent vascularity and heal- magnifier used by watch maker) it is termed as
ing capacity of these areas. a simple microscope. When two or more lenses
are used (ocular and objective lenses) then it is
The two world wars brought about a technolog- termed as the compound microscope.
ical revolution in the field of medicine. Better
equipment, anesthetic drugs, and discovery of The compound microscope was invented by
potent antibiotics tilted the balance in the favor the Dutch spectacle maker Zacharias and Hans
of surgeon. Discovery of antibiotics put an Janssen of Middelburg. The ocular lens mag-
end to an era of acute mastoiditis which could nifies the ‘real’ image formed by the objective
lead on to intra cranial complications a rarity. lens.
The number of tonsillectomies performed also
underwent a drastic reduction. The discovery
of microscope really transformed the field of
otology. Use of operating microscope helped
the surgeon to perform safe ear surgeries with
very minimal complications.

History of Operating Microscope:

For nearly 2000 years man knew that glass

bends light. In the second century BC Claudius
Ptolemy2 described that a stick appears to bend
in a pool of water. He also accurately recorded
the angles to within half a degree. He was the
first to calculate the refraction constant of water.
Early lenses were called as magnifiers / burning
glasses. The word lens is derived from the Latin
word Lentil, because it resembled the shape of

Surgical techniques in Otolaryngology

10
The early compound microscopes were very the observer’s eye. The body of the case can be
inefficient and the quality of the image was very used as a live box for storing specimen.
poor. During the first decade of the 17th centu-
ry large compound microscopes were designed. 18th century was a period of mechanical de-
The term microscope was used by Giovanni velopment of microscope. A screw barrel was
Faber4 of Germany. He was a botanist and art added to the basic design to improve focusing
collector. and superior magnification. The final form of
the microscope was established design wise.
Leeuwenhoek’s simple microscope: One basic problem existed in these microscopes
(chromatic aberration). This occurred because
Dutch surveyor Antoni van Leeuwenhoek in of different wavelengths making up the white
1673 used molten glass balls to form lenses light. Light waves of differing wave lengths are
and build crude simple microscopes that could bent at different angles by the convex lens to
magnify up to 275 times. One of the first things form this aberration. This aberration results
he examined under his new microscope was the in the formation of a series of strongly colored
scab from his own nose. fringe rings. This was overcome by design
modifications and by increasing the working
distance from the specimen.

Lister designed the first achromatic lens. It was

used by Dolland to set a standard in micros-
copy. In 1846, a German Carl Zeiss started a
microscope factory in Jena, Germany. Ernst
Abbe a physicist working with Zeiss developed
newer mathematical formulas and theories that
revolutionized lens making.

Early otological microscopes:

Three surgeons are associated with monocular

microscope. Kessel (1872), Weber-Liel (1876)
and Czapski (1888). Carl Olof Nylen was the
first to recognize the need for magnification in
ear surgery. He was responsible for developing
Image showing the Leeuwenhoek simple micro- the first monocular microscope. Emilio Rossi
scope has been quoted as the first to use a binocular
microscope in 1869. His earliest magnification
system had only a one lens system. This system
Flea glasses:
was replaced by another model developed by
Persson. One year later a binocular microscope
These glasses were used by entomologists to
developed by Zeiss factory (which had magni-
study insects. The lens is placed beneath the
fication of 6-10) was used for the first time by
acorn shaped lid. This lens is kept very close to

Prof Dr Balasubramanian Thiagarajan

Gunnar Holmgren.

First microscope 1700. (courtesy of Zu-

rich University Medical Museum)

Image showing Nylen’s monocular microscope

Surgical techniques in Otolaryngology

12
 Zeiss OPMI 1 Model (1951):

In 1951, Hans Littmann of Zeiss company de-

veloped a new binocular dissecting microscope.
This was used with great success since 1953.
This microscope had the combined advantage of
a good working distance and good illumination.
This development was done in collaboration
with Horst Wullstein and Zollner.

Image showing Binocular microscope used by

Holmgren

Technical problems of earlier binocular micro-

scope:

1. The field of view was limited to 6-12

mm
2. Working distance was only 7.5 cm Image showing Opmi 1 Zeiss microscope
3. Lack of maneuverability
4. Poor Illumination Howard House of Los Angeles summarized the
importance of microscope in ear surgery. He
Maurice Sourdille did not use the binocular said “It appears that our breakthrough is nearly
microscope, instead he preferred magnifying complete in the area of middle ear”.
spectacles. Other otologists like George Sham-
baugh, Simon Hall, Tullio and Cawthorne start- Otologists were the first surgeons to regularly
ed using microscope and continued to do so. use microscope for surgical purposes. They
were later followed by ophthalmologists and
other surgeons.

Progress in lens system and illumination pro-

vided good condition for otological surgeries.
Conditions for good microscope include:

Prof Dr Balasubramanian Thiagarajan

1. Binocular vision
2. Magnification between 6 and 16x
3. Ability to modify magnification without
changing the working distance (20 cm)
4. Visual field of 20 mm
5. Coaxial illumination system
6. Good stability with total mobility in all
axes

Increasing stability of the microscope allowed for

attachment of accessory equipment like photo-
graphic cameras / other documentation systems.

Stereoscopic 3 D vision:

This is rather important for the surgeon engaged

in training students. This need gave birth to
3D video microscope. In order to produce 3
D image, two cameras are used to record the
microscopic image that can be transmitted to
the central module (the monitor). The monitor
turns the signals received from the cameras into
a double image. This requires special eye glasses
to be used. 3D image can also be produced by
image reconstruction algorithm.

Surgical techniques in Otolaryngology

14
 Historical aspects of Otolaryngological Surgery

History of Paranasal sinus surgery: At this point it is worth narrating an interest-

ing story about an English anatomist who was
Introduction: consulted by a patient who had a continuous
flow of pus after extraction of upper canine
The Latin word “sinus” represents the geograph- teeth. The patient attempted to insert a pencil
ic term indicating a creek or a bay. The medical into the extraction cavity, it went in for about an
resources of Ancient Egypt (3700 and 1500 BC) inch. Anatomist then consulted Highmore who
indicated that the anatomy of nasal sinuses were explained to him the anatomical relationship of
known at that time. This resource also described antral cavity with that of dentition.
details of various treatments available at that
time. This deep knowledge of anatomy of nose Improvement of anatomical knowledge led to
and sinuses according to Edwin Smith’s papy- evolution of surgical approaches to sinus cavities.
rus was attributed to the fact that during the In 1743 Montpellier, Louis Lamorier gained ac-
mummification rituals the brain of the dead was cess to maxillary sinus cavity via the oral cavity.
remove via the nostrils, presumably by passing This approach was later published in 1768. Den-
via the ethmoid cells. tal surgeon by name Anselme L.B.B.Jourdain in
1816 treated suppurative maxillary sinusitis with
In the Hippocratic Corpus (460-377 BC) there saline irrigations via the natural ostium. But this
were indications for the therapy of rhinosinusal procedure unfortunately did not meet with the
polyposis. Aulus Cornelius Celsus (14 BC) desired success.
described paranasal sinus anatomy with a great
degree of accuracy. The first accepted reference material for normal
and pathological anatomy of nose and sinuses
In the 16th century, Sansovino described para- was published by Emil Zukerkandl in 1882. In
nasal sinuses as “cloaca cerebri”, i.e. the cavities this work the nose was considered to be part of
responsible for the drainage of “corrupted spirits” the surrounding sinuses.
from the head. In 1452 - 1509 Leornodo da Vin-
ci recognized the relationship between maxillary Origins of paranasal sinus surgeries:
sinus and the teeth. He documented it in his
drawings and paintings. Ludwig Grunwald narrated how acute and
chronic inflammations were the basis of sinusitis.
The clearest idea of anatomy of nose and sinuses Historic medical literature reveals that during
was provided by the great anatomist Berengario the 1st century in Pompei, speculum shaped
da Carpi. Andrea Vesalio in his important doc- nasal dilators were used for visualization of nasal
ument “De Humani corporis Fabrica” described cavities.
maxillary, frontal and sphenoid sinuses. He also
claimed that these spaces were filled with air. The chance of surgical drainage of nasal sinuses
More accurate studies were performed by Giulio was considered only from 17th century. Towards
Cesare Casseri. He named the maxillary sinus as the 19th century several surgeons considered
“antrum Casserii”. explorative puncture of maxillary sinus. Johann
von Mickulicz-Radecki 1905 suggested that max-

Prof Dr Balasubramanian Thiagarajan

illary sinus antrum can be reached via the middle wide that the patient was able to perform antral
meatus. He was in fact the first surgeon to intro- irrigations.
duce the concept of antrostomy for drainage of
maxillary sinus. One year later Hermann Krause Kubo and Gerber expressed their preference
a German surgeon modified that technique by for antrostomy executed via the middle meatus.
adding a drainage tube to the antrostomy. They used a perforated designed by Onodi in
1902. Several techniques were used to access the
Karl K.H. Ziem described how the pathology of maxillary sinus cavity. Hall stated that inferior
maxillary sinus could be resolved through alve- meatus approach to maxillary sinus was the most
olar surgical access. Three years after him, Ernst correct one, on the other hand Lavelle and Harri-
G.F. Kuster proposed the validity of sublabial son found a higher rate of healing and lower in-
approach in drainage of maxillary sinus cavity. cidence of complications in patients with chronic
He usually created an opening in the canine fossa sinusitis treated by opening the middle meatus.
area, of the size of little finger. He used to oc- He suggested that physiologic pathway of drain-
clude the opening with rubber plug after washing age should be widened for optimal results. Mck-
its contents out. enzie described a combination of middle and
inferior meatal antrostomies. Sluder practiced
In 1893 George Walter Caldwell suggested the a more drastic surgery wherein he removed the
possibility of creating a window in the lateral entire medial wall of maxillary sinus preserving
wall of the inferior meatus via the canine fossa. only the inferior turbinate.
This approach was performed for the first time
in Europe in 1896 by Georg Boenninghaus. An Harris Peyton Mosher of Harvard University after
absolutely identical procedure was described by his detailed study of anatomy of paranasal sinus-
Robert H.S. Spicer and Henry Paul Luc in Lon- es by dissecting a number of cadaver specimen
don. A combination of procedures advocated said: “If it were placed in any part of the body it
by these surgeons was evolved where in a count- would be an insignificant and harmless collec-
er-opening of maxillary sinus was made via the tion of bony cells. In the place where nature has
inferior meatus in addition to the canine fossa put it, it has major relationships so that diseases
opening. and surgery of the labyrinth often lead to trage-
dy. Any surgery in this region should be rather
Gustav Killian described the resection of the simple, but it has proven to be one of the easiest
uncinate process with enlargement of nearby ways to kill a patient”. In 1912 he used intranasal
ostium. Halle was the first author to claim a large ethmoidectomy for the treatment of chronic eth-
personal experience on intranasal ethmoidecto- moiditis. Subtotal resection of middle turbinate
my, and frontal and sphenoid sinusotomies. He provided a better control of the sphenoidal region
stressed the importance of uniting all the cells of and posterior ethmoidal space making the sur-
ethmoid into a single common cavity. gery safer. This very same technique was adopted
by Yankauer, Lederer, and Weille.
In 1909, Dahmer performed an inferior meatal
antrostomy by cutting the anterior part of the Freedman and Kern emphasized the importance
inferior turbinate. The resulting opening was so of middle turbinate’s preservation for the preven-

Surgical techniques in Otolaryngology

16
tion of mucosal dryness due to enlargement of improve the drainage. In 1898 Riedel performed
the volume of nasal cavity. obliteration of frontal sinus. He advocated com-
Hence the term “ethmoidectomy” indicated an plete removal of anterior table and floor of frontal
opening restricted to few ethmoidal cells while sinus with stripping of mucosa. He performed
the term “total ethmoidectomy” included open- this procedure in a patient with osteomyelitis of
ing off sphenoid and maxillary sinuses as well. frontal bone. This procedure caused an unsight-
ly deformity of skull. Killian in 1903 advocated
The first approach to frontal sinus was derived retention of 1 cm bar of supraorbital rim. Killian
from ophthalmology. Alexander Ogston a Scot- was able to avoid deformity by retaining this bar
tish ophthalmologist managed to reach frontal si- of bone. Killian also advocated ethmoidectomy
nus via a horizontal incision performed under the combined with rotation of mucosal flap to cover
eyebrow and drilling the bone thereby creating the frontal recess area. Killian’s procedure was
a breach sufficiently wide to allow the opening fraught with complications like Restenosis, supra-
of both frontal sinuses. This technique was then orbital rim necrosis, post op meningitis, muco-
described in 1894 by Luc, who used it to insert a cele formation etc.
drainage tube into the frontal sinus. This surgery
was known as Ogston-Luc procedure. Era of conservative procedures (1905):

Major advantage of conservative procedure is

avoidance of cosmetic defects. Conservative
procedures involved intranasal approach to fron-
tal sinus. It was Knapp in 1908 who performed
external Fronto ethmoid surgery. He approached
the frontal sinus through its floor, removed the
diseased mucosa and stented the Fronto nasal
duct to prevent Restenosis.

In 1908 Halle chiseled out the frontal process of

maxilla and used a burr to remove the floor of
frontal sinus.

In 1914 Lothrop enlarged the frontal sinus

Alexander Ogston drainage pathway using intranasal approach. He
combined intranasal ethmoidectomy with exter-
Era of radical ablation procedures (1895): nal ethmoidal approach. He managed to create a
common frontal nasal communication by remov-
Kuhnt in 1895 described a procedure wherein ing the frontal sinus floor, intersinus septum and
he removed the anterior wall of frontal sinus in the superior portion of nasal septum. He also
an attempt to clear the frontal sinus of the dis- said that resection of medial orbital wall caused
eased mucosa. He stripped the mucosa up to the prolapse of orbital contents into the ethmoid area
frontal recess and stented the frontonasal duct to causing obstruction to frontal sinus drainage.

Prof Dr Balasubramanian Thiagarajan

 technology in order to design this device. He
External fronto ethmoidectomy 1897 – 1921: did this by devising a system of double alumi-
In 1897 Jenson performed the first external num tubes equipped with strategically angled
Fronto ethmoidectomy in Germany. Lynch mirrors (flat, concave and convex) that were
and Howarth in 1921 popularized resection of positioned in such a way as to bring the image
floor of the frontal sinus with dilatation of the back to his eye while simultaneously conveying
frontal sinus outlet via external approach. This the distally placed candle light into the interior
approach is hence known as Lynch Howarth body.
procedure. A curvilinear incision is made just
below the medial end of eyebrow. It is curved Endoscopic intranasal approach:
medial to the medial canthus. The frontal
process of maxilla and lamina papyracea is re- With the advent of nasal endoscopes (angled)
moved. Frontal sinus is entered via its floor and approach to the frontal sinus outflow tract has
the lining mucosa is curetted. A stent is placed become easy.
in the frontal sinus ostium to prevent stenosis.
The stent is left in place for a period of 4 weeks. History of Endoscopic Sinus Surgery
Boyden used silicone tube to prevent stenosis.

The first recorded instance of endoscope be-

Osteoplastic anterior wall approach (1958): ing used for visualization of nasal cavity was
by Hirschmann of Berlin in 1901. Alfred
This procedure became popular during 1960’s. Hirschmann was in the occupation of designing
Backer introduced radiographic plate to outline medical instruments. He modified a cystoscope
the frontal sinus. This procedure was fraught and used it to view the insides of nasal cavity.
with the risk of hemorrhage. In 1903 he published a paper titled “Endoscopy
of nose and its accessory sinuses”. In 1910, M
Zukerkandl studied sphenoid sinus drainage Reichart performed the first endoscopic si-
pathway, and he stated that it was possible to nus surgery using a 7mm endoscope. In 1925
reach this area via nasal cavities. His studies Maxwell Maltz created the term “sinuscopy” for
represent the basis for the trans-nasal-sphenoid the first time referring to the endoscopic meth-
surgery of pitutary gland. od of visualizing the sinuses. He was the one
to first encourage routine use of endoscopy as
Light source: a diagnostic tool in examination of nose and its
sinuses.
Bozzini was the first to describe an ante litteram
light source. He used his physics knowledge Walter Messerklinger working in the city of
to create a Lichtleiter (light conductor) which Graz, Austria performed basic research on mu-
allowed him to explore and examine the external cosal transport mechanism. He developed the
auditory canal, the nasal cavities and orophar- surgical principles in the management of chron-
ynx. Bozzini was the first to adopt existing lens ic sinusitis. His techniques later became popular

Surgical techniques in Otolaryngology

18
as the Messerklinger’s technique of endoscopic He developed the concept of major sinuses like
sinus surgery. frontal and maxillary sinuses were dependent
sinuses. Their drainage depended on a clear
anterior ethmoid cell structures in the middle
meatus. This zone was later christened as the
‘Osteomeatal unit’ by Naumann. This concept
was further popularized by David Kennedy of
United States.

Walter Messerklinger

In 1950’s and 1960’s Messerklinger mapped the

mucous transport routes in the nose on ca-
davers. In cadavers’ cilia continues to beat for
48 hours after death, hence they provided an
excellent model for the study. He placed Indian
ink particles inside the maxillary sinus cavity
and identified that maxillary sinus mucosal flow
was always towards the natural ostium, and then Heinz Stamberger
backwards through the middle meatus into the
postnasal space. This explained the failure of Surgeons from other European centers like
traditional Caldwell-Luc procedures and maxil- Malte Wigand of Erlangen and Wolfgang Draf
lary sinus punctures, because they depended on of Fulda Germany were also working on the
gravity for drainage of mucous secretions. concept of endoscopic sinus surgery. Draf used
a combination of rigid telescopes and operating
Messerklinger in 1960’s used a modified cys- microscope to drill out frontal sinus in recalci-
toscope and performed sinus surgeries under trant cases. Malte Wigand used an alternative
local anesthesia. He tailored the surgical proce- approach to manage sinus drainage problems.
dure according to the cause of obstruction. The He used a combination of headlight and suc-
surgery was minimalist in nature and concept. tion endoscopy in a gun like instrument with a

Prof Dr Balasubramanian Thiagarajan

handle. He opened up the sphenoid sinus and his left hand.
then proceeded to dissect anteriorly. This poste-
rior to anterior dissection of sinuses goes under History of mastoid surgery:
his name “Wigand technique”. In this technique
the disease was pursued and removed rather than Introduction: “One who ignores history would
being left to resolve spontaneously unlike the do so at his peril, to be condemned to repeat the
Messerklinger ventilation concept. same mistakes”. A study of history of mastoid
surgery and its instrumentation is important in a
Path breaking developments that opened up new sense that they are the tombstones to our success
vistas in endoscopic sinus surgery: today. Eighteenth century is characterized by
advancement in instrument designs and steril-
Development of miniaturized telescopes at Read- ization techniques. Heat resistant metals were
ing University UK 1951 and development of CT used to manufacture surgical instruments as they
scan by Godfrey Hounsfield of Hayes London had to withstand extremely high sterilization
opened up new vistas in endoscopic sinus sur- temperatures. Our forefathers of 18th century
gery. were great innovators and to their credit even
now majority of mastoid instruments in use were
Endoscopic sinus surgery was not popular conceived and designed by them.
among British surgeons because Messerklinger
who is the father of endoscopic sinus surgery did Mastoidectomy during different eras:
not speak English and he delivered all his lectures
in his native tongue German. It was left to his The art and craft of Mastoidectomy has evolved
assistant Heinz Stamberger who spoke fluent En- during the past 200 years. The process of this
glish to popularize the technique among English evolution can be studied under three different
speaking surgeons. eras i.e.:

David Kennedy (ENT Resident) at Johns Hop- 1. Era of trepan (18th century)
kins Medical School Baltimore was asked to
review the paper published by Messerklinger 2. Era of chisel & gouge (Early 19th century)
titled “ Endoscopy of the nose”. He became so
enthused that he made it a point to learn the 3. Era of electrical drill (20th century)
technique himself. David Kennedy along with
Stamberger popularized Messerklinger technique Era of Trepan:
all over the English-speaking world.
Trephination was performed to let out pus. This
Endoscopic sinus surgery initially was performed was extensively practiced during the 18th century
with a Wittosmer side arm attached to a beam to let out pus from skull bones. The first success-
splitter placed on the eyepiece of the telescope ful trephination of mastoid cavity was performed
so that the observer could view the surgery. The by Ambroise Pare during 16th century. Young-
observer usually stood on the opposite side of the er during 17th century devised a hand Trepan
table and would support the bulky side arm with which he used extensively to perform this pro-

Surgical techniques in Otolaryngology

20
cedure. A handheld trepan was commonly used
during this period. The cutting head of trepan Modern mastoid surgery was pioneered by the
used could be circular (to cut a circular piece of German otologist Scwartze during 1873. He and
bone), exfoliative head (to shed the superficial his assistant Adolf Eysell abandoned the use of
layer of bone), and perforative head (used to Trepan in favor of chisel and gouge. He popu-
make a hole in the bone). In 1736 Jean Louis larized Chisel and gouge as he was convinced
Petit performed the first mastoid opening for a that it was the safest way to open up the mastoid
patient with mastoid abscess. Pus His main aim antrum. His assistant had drawn up detailed
was to create a hole through which pus from the illustrations of the various types of chisel and
mastoid cavity can drain. While using a Trepan gouges used in this procedure. Buck introduced
it should be dipped in cold water often to reduce the small curette that could be used to widen the
heat generated during the procedure. aditus. He also advocated continuous chiseling
of the hard mastoid cortex till the soft bone is
In 1776 Jasser used a trocar to open up the reached which could be curetted out rather easily
mastoid cavity. He used the nozzle of a syringe using curettes of varying sizes.
to aspirate the contents from the mastoid cavity.
This surgical procedure hence was aptly named Initially Volkmann sharp edged spoons were
as “Jasser procedure”. The term “trocar” has its used as curette. Samuel Kopetzky, American
origin in French language. “Toris – quarts” is otologist advised that one should become dex-
a French word to describe an instrument with terous and elegant with the use of a set of instru-
three cutting sides used to make a hole. Amer- ments. Newer instruments (design wise) should
ican otologist Fredreik White described this era be introduced only when they have distinct
of mastoid surgery as an experimental one. This advantages over the tried out older ones. This
experimental era proved that the concept of observation holds good even today.
opening up the mastoid cavity and draining the
secretions is a possibility. The instrumentation Electrically driven drill period: “Modern era
was of course woefully inadequate. The first Mastoidectomy”
catalogue of surgical instruments published in
1860’s mentioned the various surgical and dental Electrically driven drills were used to manage
instruments in use. Mastoid instrumentation of dental caries even way back in 1882. It was
course did not find a place in that catalogue. William McEwen who drew the attention of the
world to this unique device. He believed that
Chisel & Gouge period: the safest instrument that can be used to drill the
mastoid antrum is the rotating burr. It had better
This period was characterized by the introduc- control and uniform rotator cutting ability. The
tion of general anesthesia which facilitated a size of the burr bits can vary according to the
surgeon to operate leisurely on a patient. It was area of surgery. It was Julius Lempert in 1922
Amedee Forget a French surgeon who used a who really popularized the use of electrically
mallet and gouge to open the mastoid cavity and driven drill in ear surgeries. William House
drain the accumulated pus. He performed this introduced the suction irrigation system and
surgery during 1860. retractors in mastoid surgery. He observed that

Prof Dr Balasubramanian Thiagarajan

while performing ear surgeries a surgeon needs
to keep both hands useful.

Holmgren introduced the operating microscope

which really made Mastoidectomy totally a safe
procedure.

Surgical techniques in Otolaryngology

22
 Role of Microdebriders in Otolaryngology

Introduction:
The originally patented Vacuum dissector was
Microdebrider should be considered to be next cylindrical, electrically powered shaver system
only to an endoscope in rhinological surgical which is supplied with continuous suction. The
procedures. It is hence considered to be the most basic design which was patented has a hollow
important innovations in shaft with a rotating / oscillating inner cannula.
the field of rhinology and endoscopic sinus sur- The suction applied draws the soft tissue in-
gery. In recent times this instrument is becoming wards and is trapped there. This trapped tissue
really popular thereby reducing the reliance on is sheared off by the rotating blade between the
traditional non powered inner and outer cannulas.
sinus instruments like curettes and forceps. The slower the rotating speed of the blade larger
is the tissue bite, at higher speed rates the instru-
Advantages of Microdebrider include: ment becomes less aggressive. The sheared bits of
tissue are sucked by the suction effect. Irrigation
1. It spares the adjacent mucosa (Mucosal spar- via a side portal is performed in a continuous
ing) basis.
2. It is precise
3. Removes tissue real fast Irrigation helps in preventing the bits of tissue
4. Visualization is really good from blocking the suction portal of the hand
5. Since the blade comes in different angles it can piece. The bits of tissue sheared by debrider blade
be used to cut tissues from can be collected and sent for histopathological
even inaccessible areas inside the nose examination also.
6. The suction applied to the blade sucks and
holds the tissue for better cutting Hand piece design:
effect
All the commonly used debrider hand-pieces still
History: maintain the cylindrical design of the original
patent of Urban. The cylindrical design permits
Originally the concept and design of Microde- the surgeon to hold the hand piece as if it were a
brider was patented by Urban in 1969. scalpel.
In his patent application he called the equipment
“Vacuum rotatory dissector”. This equipment was The Diego Microdebrider provides a pistol grip
originally used by the House group to remove hand-piece. Some surgeons find this comfortable.
acoustic neuroma during 1970’s. Orthopedic sur-
geons started using it for arthroscopic surgeries With the image guidance systems becoming
from the year 1975. common hand-piece manufacturers have made
hand pieces that can be easily coupled with image
It was only from the year 1994 Setliff and Parsons guidance system.
started using this equipment for nasal surgeries.
Improvements to this original vacuum dissector
started taking place by leaps and bounds.

Prof Dr Balasubramanian Thiagarajan

 Debrider blades:

These blades are disposable. They come in var-

ious configurations. Their edges can be straight
or serrated. Straight edged blades are less trau-
matic and has more tissue sparing effect, whereas
serrated ones allow for better gripping of tissue.
It has an inner and outer cannula. The inner
cannula’s edge happens to be the blade. The outer
cannula serves as a conduit for suction, irrigation
and the inner cannula.

Depending on the relative angles of the inner and

outer cannulas the cutting action of the debrider
blade could either be guillotine or scissors. Most
of the debrider blades has a scissors like cutting
action with an angle between the openings of
the inner and outer cannulas hence the shearing
Image of Microdebrider hand piece force is applied only to a small tissue area at a
given time. In debrider blades with a guillotine
cutting mechanism the apertures of the two can-
nulas run parallel to one another hence it shears
off the entire bit of tissue.

Figure showing pistol grip hand-piece

Figure showing the two basic types of debrider

blades

Surgical techniques in Otolaryngology

24
These blades can either be set to oscillate or Tonsillectomy blades:
rotate. Oscillation usually runs at a slow speed
(5000 rpm) and is useful for soft tissue resection. These blades are used to perform extra capsular
At slower speeds the port remains open longer tonsillectomy. These blades are wider with low
allowing more soft tissue to be drawn into the angles to enable it to function as a guillotine.
aperture before the cut could be made. This adds These blades usually come in 4mm diameters.
to the efficiency of soft tissue resection.
Adenoidectomy blades:
Forward and reverse rotations are faster (up
to 15,000 rpm) and has a drill like action and These blades are curved and hence can be intro-
hence could be used to drill bony structures as duced through the nasal cavities. The curvature
in endoscopic dcr, reduction of bony septal spur of these blades mimics the curvature of the nasal
etc. Since the speed is too low for drilling bony cavity.
structures when compared to the mastoid micro-
drills, it takes a long time to drill bony structures
using a Microdebrider. Recent innovations in
Microdebrider blades is the availability of blades
which are prebent to suit the various angulations
of resection inside the nasal cavity.

Figure showing the debrider blade used for ade-

noidectomy

Image showing the prebent Microdebrider

blades

Special Microdebrider blades:

These blades are made to perform specific tasks.

Prof Dr Balasubramanian Thiagarajan

Figure showing debrider blade used in tonsillec-
tomy
Figure showing turbinectomy blade

Turbinectomy blades:
Role of debriders in clearing up the operating
These blades are used to perform inferior turbi- field:
nectomy. These blades are small diameter blades
(2-2.8 mm). It has a beveled guard at the back Clearing the operating field of blood and other
which protects the turbinate mucosa while the secretions is a must for better visibility during
vascular erectile tissue is being dissected. This nasal endoscopic sinus surgery. Even small
mucosal protection causes lower incidence of amounts of bleeding can significantly impair
osteitis of the inferior concha. visibility during endoscopic surgeries. Debriders
have the ability to continuously suck blood and
Turbinectomy blades: dissected tissues out of the surgical field is a great
advantage.
These blades are used to perform inferior turbi-
nectomy. These blades are small diameter blades Recent modifications in debrider technology
(2-2.8 mm). It has a beveled guard at the back have managed to add the ability to cauterize
which protects the turbinate mucosa while the bleeders using bipolar cautery delivered via the
vascular erectile tissue is being dissected. This end of the blade. These blades themselves are sur-
mucosal protection causes lower incidence of rounded by layers of insulation causing a sand-
osteitis of the inferior concha. wiching of the inner and outer electrodes. These
instruments can be set to cauterize bleeders in
three settings:

1. Low – 10 Watts
2. Medium – 20 Watts
3. High – 40 Watts

Surgical techniques in Otolaryngology

26
The only drawback of these blades is that only a Where do you use Microdebrider drill bits?
small zone of bipolar cautery is present.
1. In Endoscopic DCR
Microdebrider drills: 2. In frontal sinus surgeries
3. In trans sphenoid pituitary surgeries
Even though Microdebriders are not suited for 4. In Endoscopic skull base surgeries
drilling bone, the thin ethmoidal bones
can easily be drilled using drill bits in place of de- Limitations of Microdebrider:
brider blades. These drill bits are commonly used
in endoscopic dacryocystorhinostomy proce- 1. Slow rotation rates – Debrider rotate at slow
dures. These drill bits are diamond drill bits (2.5 rates (15,000 rpm) as compared to that of micro-
mm) size. The number of grooves in the drill bit drills (80,000 rpm) thus making it inefficient to
determines the speed of drilling. Fewer grooves drill bony structures.
result in faster and aggressive drilling of bone. 2. Tactile feedback is less while operating with
This always comes with a price (poor control). As Microdebriders when compared to that of con-
the number of grooves in the drill bits increas- ventional instruments
es, the bone take down rate slows down but the 3. It should be used carefully in confined spaces
control is much better. Diamond burrs cause less close to vital structures in order to avoid damage
aggressive drilling than normal burrs. to them
4. Initial cost of equipment and recurring ex-
penses incurred towards purchase of blades
increase the cost of surgery.

Various components of Microdebrider:

A debrider contains three components.

1. The console which helps in controlling the
speed of rotation/direction of rotation. These
parameters can easily be changed with the help of
an attached foot pedal.
2. The blade: This is a tubular metal structure
with serrated edge / smooth edge. The cutting
edge is present only on one side only, while
the smooth opposite surface does not cut. It is
usually connected to a suction tube. These blades
come in various sizes and configurations. This
Figure showing sheathed Microdebrider drill blade allows for simultaneous cutting and remov-
bits al of cut tissue by suction.
3. Hand piece: Which is a portable micro motor.
It derives its power supply from the console. The

Prof Dr Balasubramanian Thiagarajan

blade is attached to the shaft of the hand piece.

Image showing console of Microdebrider

Image showing debrider in action

Surgical techniques in Otolaryngology

28
 Otology

2. Modified radical mastoidectomy

Mastoidectomy An Introduction
3. Open technique

Introduction: 4. Front to back mastoidectomy

Mastoid surgeries are performed to eradicate 5. Attico antrostomy

middle ear disease. A number of vital structures
are in close proximity / located inside the tem- 6. Open mastoidoepitympanectomy
poral bone. A thorough knowledge of temporal
bone anatomy is a must for all otologists. Sur- Aims of Mastoid surgery:
geon who attempts this surgery without ana-
tomical knowledge is sure to fall into the pit of 1. Eradication of mastoid and middle ear disease
complications. Anatomy of the temporal bone is and prevention of residual disease
highly variable. The surgeon should be aware of
all these variations. The mastoid portion of the 2. Improving middle ear ventilation and preven-
temporal bone has varying thickness of corti- tion of recurrent disease
cal osseous covering. This is filled with air cells
which are Septated. This is similar in appearance 3. To create a dry and self-cleansing cavity
to ethmoidal sinuses.
4. Reconstruction of hearing mechanism. The
Types of Mastoidectomy: terms open and closed mastoidectomy are com-
monly used these days. Common to both open
Various types of mastoidectomies are performed. and closed mastoidoepitympanectomy is the
They include: bony work involving the mastoid cavity. It in-
volves identification of the important landmarks
Canal wall up mastoidectomy: (this implies that skeletonizing a thin shelf of
bone covering the important structure) before
1. Combined approach attempting to remove the disease and creating
maximum exposure for complete exenteration of
2. Intact canal mastoidectomy the disease.

3. Close technique Canal wall down mastoidec- Closed technique:

tomy
In this technique the posterior canal wall is kept
1. Radical mastoidectomy - The classical radical in place and dissection is performed trans canal
mastoidectomy is not performed for eradication after a proper Canalplasty. It can be performed
of inflammatory pathology as it results in a large via Transmastoid approach also (post auricular
cavity that frequently discharges. This procedure incision).
is reserved only for middle ear malignancies.

Prof Dr Balasubramanian Thiagarajan

Open Mastoidoepitympanectomy: temporomandibular joint which lies anteriorly.
This is achieved by drilling the bony portion of
This involves complete exenteration of the the external auditory canal. Drilling is focused
mastoid air cell system and the epitympanum. on the posterior wall, superior wall and inferior
This includes removal of incus and mastoid wall of the bony external auditory canal. Before
head, exenteration of the supralabyrinthine and drilling the skin lining of the external canal
supratubal cells. This procedure is indicated in should be reflected to expose the bony portion
poorly pneumatized and ventilated ears with of the external canal.
limited access and exposure. In this procedure
the the facial nerve is skeletonized along its Epitympanotomy:
mastoid segment. This is done by lowering the
posterior canal wall up to the level of the facial This involves removal of outer attic wall to ex-
nerve. A thin layer of bone is left over the facial pose the head of the malleus and incus and the
nerve. The mastoid area behind the facial nerve soft tissue pathology in the attic area is removed.
is obliterated with a muscle flap to keep the final In order to remove the soft tissue pathology
volume of the mastoid cavity low to prevent from the anterior epitympanum the head of the
discharging ear. malleus need to be clipped to get access to that
area.
The other method open mastoidectomy could
be performed (canal wall down) is front to back Epitympanectomy:
mastoidectomy. This approach can be selected
when a prior decision has been made in advance In this procedure after removing the outer
to bring down the posterior canal wall and the attic wall the incus and head of the malleus are
mastoid is sclerotic. The only draw back of this removed to get access to the entire attic. This
procedure is difficulty in removing all mastoid procedure also exenteration of the supralabyrin-
air cells. Leaving behind some cells would result thine cell tracts.
in a discharging cavity. Some of the terminol-
ogies used in mastoid surgeries: Cortical Mas- Posterior tympanotomy:
toidectomy: This is also known as the simple
mastoidectomy involves opening of the mastoid This is also known as Facial recess approach.
cortex and identification of the aditus ad an- This approach was initially used to approach the
trum. The aditus is widened as much as possible. hypotympanum air cells. Currently this ap-
The intention of this surgical procedure is to proach is used for cochlear implant procedures.
reventilate the middle ear cavity. A fully ventilat- In this procedure a window is opened from the
ed middle ear cavity is free of disease. mastoid to the middle ear between the facial
nerve and the chorda tympani. This is created
Canalplasty: after performing cortical mastoidectomy.

This surgery attempts to enlarge the external

auditory canal without causing injury to the

Surgical techniques in Otolaryngology

30
 riorizing the surgical cavity. The posterior canal
Indications: wall is lowered up to the level of the facial nerve
canal. In order to reduce the size of the cavity,
1. Performed as a part of closed mastoidoepi- the mastoid tip is removed and a myosubcutane-
tympanectomy (combined approach) in order to ous occipital flap is created to reduce the size of
remove cholesteatoma from the hypotympanum the cavity. Meatoplasty is routinely performed.
Age is not a limitation for open mastoid proce-
2. To remove pus from the region of the round dures it can be performed with good effect even
window in acute bacterial / viral otitis media in children.
with sensorineural hearing loss

3. To provide access to promontory & round

window in cochlear implant surgery Indications for open mastoidectomy:

4. To access the incus / round window with 1. Large cholesteatoma

insertion of the vibrant sound bridge
2. Labyrinthine fistula

Closed mastoidoepitympanectomy with tym- 3. Cholesteatoma with complications

panoplasty:
4. Recurrent cholesteatoma after previous closed
This process includes: mastoidectomy

Canalplasty 5. Poorly pneumatized mastoid

Mastoidectomy 6. Extensive granulation tissue in the middle ear

cavity
Epitympanectomy
7. If the patient is not reliable for follow up
Posterior tympanotomy
Indications for closed mastoidectomy:
Tympanoplasty
1. Limited disease
The external bony canal is preserved. The only
drawback of this procedure is the view to the 2. If pneumatization is normal and space is
anterior epitympanum is very limited. Sinus sufficient
tympani view is also rather limited. Open mas-
toidoepitympanectomy with cavity obliteration: 3. If ventilation is normal in middle ear and
This procedure involves radical exenteration of mastoid air cells
the tympanomastoid air cell tracts thereby exte-

Prof Dr Balasubramanian Thiagarajan

4. If the patient would come for regular follow Canalplasty needs to be done by drilling the an-
up terior wall which could be close to the temporo-
mandibular joint. Close to the posterior wall
Investigations: mastoid air cells are present. These should not
be breached while performing a Canalplasty.
1. Pneumatic otoscopy should be performed to
determine the presence of labyrinthine fistula. A 4. Size and presence of mastoid emissary vein. A
positive response will always indicate the pres- large mastoid emissary vein can cause trouble-
ence of a fistula while a negative test does not some bleeding if it is not anticipated.
exclude it.
5. Sigmoid sinus and its relation in the mastoid
2. Pure tone audiometry to assess the hearing cavity should be studied. In children the sigmoid
levels may lie close to the lateral surface of the mas-
toid, hence can be easily injured while drilling in
3. HRCT temporal bone: All patients undergo- this area. In adults sigmoid sinus malformation
ing mastoid surgery should have a preop HRCT may be appreciated in the preop CT scan. If the
imaging (1/2 mm cuts). The following should be sigmoid sinus lies very anteriorly in the mastoid
looked out for in HRCT: cavity it may be difficult to perform posterior
tympanotomy due to the limited space available.
1. Extend of pneumatization of temporal bone. In the case of revision surgery, CT image will
It will reveal whether pneumatization is normal, reveal whether sigmoid sinus has been exposed
poor or the mastoid is sclerotic. This gives an during the previous surgery or if there is any
important input about the eustachean tube func- bony covering left. If the sigmoid sinus was
tion during the first 4 years of the patient’s life exposed during the previous surgery then scar
was like. Poor ventilation and pneumatization formation in that area will make it difficult to
needs open cavity procedure. elevate tissue in that area without breaching the
sigmoid sinus. This can very well happen when
2. To assess ventilation. This can be done by the periosteal flap is elevated.
assessing the aeration of the middle ear and
mastoid air cells which could be clearly seen in 6. Jugular bulb. CT image should be studied for
the CT images. Opacification of the middle ear high riding position. If it is dehiscent it will also
or mastoid air cells would suggest poor ventila- be evident in the scan.
tion of middle ear cleft. Poor ventilation in the
already impaired pneumatized cell tracts would 7. Carotid artery. Images should be studied to
favor an open cavity procedure. look out for dehiscence at the level of the eusta-
chean tube.
3. Study of the bony external auditory canal.
Thickness of the bony portion of the external 8. Tegmen tympani. The shape of the tegmen
auditory canal both anteriorly and posteriorly should be studied. The following details should
should be assessed. This is important when a be looked into: Is the tegmen flat, or does it

Surgical techniques in Otolaryngology

32
slope upwards with air cells lying medial to it or the area and also serves to reduce immediate
whether it is low lying. Tegmen should also be post op pain.
looked out for dehiscence. A bony defect in the
tegmen tympani or anterior wall of the epitym- Incision: Post aural incision of William Wilde
panum should raise the suspicion of an encepha- is used. A curved incision is made about 1.5 cm
locele / cholesteatoma extending into the middle behind the post auricular sulcus with a 15 blade
cranial fossa. If dehiscence is present, then MRI knife. The incision begins from just above the
should be performed to glean more details. linea temporalis and extends up to the mastoid
tip. Care must be taken not to place the incision
9. Facial nerve. The tympanic segment may be over the post auricular sulus as it would enter
dehiscent, this is common in children. In the into the external auditory canal.
presence of cholesteatoma, the tympanic seg-
ment of facial nerve can be exposed due to bone Elevation of periosteal flap: Anteriorly based
erosion. In the case of revision surgery a prior periosteal flap is developed about 1.5 cm in
knowledge of exposed facial nerve will prevent length. Periosteal elevator is used to elevate
its inadvertent damage during elevation of tym- the flap from the bone until the spine of Hen-
panomeatal flap. le’s spine is visualized and the entrance of the
external auditory canal comes into view. A
10. Presence of fistula over lateral canal can be roller gauze is inserted through the flap and the
visualized flap is pushed anteriorly and held away from
the surgical field exposing the external audito-
11. Extent of the disease can be assessed. ry canal. Self-retaining retractors are used to
retract the flap. Retractor exposes the field to
12. Status of the ossicular chain can be studied the surgeon allowing the surgeon to have both
the hands free. Retraction also reduces bleeding
Mastoidectomy can be performed under both from the area. If there are any bony overhangs a
Local anesthesia and General anesthesia. Canalplasty needs to be performed. It is always
ideal to perform this procedure always as it de-
fines the anterior limit of the surgery. The entire
Positioning: The patient is positioned supine annulus should be visible.
with head rotated away from the surgeon. Over
extension of neck should be avoided specifically Tympanomeatal flap:
in children as it could cause atlantoaxial sublux- The posterior meatal skin flap is elevated to-
ation. wards the annulus. Cotton ball soaked in adren-
aline is used to push the flap in order to reduce
Infiltration: Post auricular skin incision area is bleeding. Suction is avoided over the flap. The
infiltrated with 2% xylocaine with 1 in 200,000 annulus should be elevated from the sulcus
adrenaline. Infiltration serves to elevate the skin exposing the middle ear mucosa. The middle ear
and periosteum in that area. It also serves to mucosa is incised with an angled picked thereby
reduce bleeding during surgery. It anesthetizes entering into the middle ear cavity. The entire

Prof Dr Balasubramanian Thiagarajan

middle ear cavity can be inspected and disease plate is followed posteriorly up to the sinodural
inside the middle ear can be removed. angle which is actually the area between the
sigmoid sinus and the dura. The dural plate can
Antrostomy and mastoidectomy: be identified by the change in color of the bone
This should always be performed. The prin- and the change in the pitch of the burr. The
cipal surgical landmarks are linea temporalis sigmoid sinus is skeletonized. A thin covering
superiorly, bony ear canal and spine of Henle of bone should be left over the sinus. The lateral
anteriorly and the mastoid tip posteriorly. These and posterior semicircular canals are identified
surgical landmarks should be identified and and the retrolabyrinthine cells are exenterated.
exposed. While elevating the periosteum pos- The facial nerve should be identified next. The
teriorly one can encounter mastoid emissary superior landmark for the mastoid segment of
vein inferior to the mastoid tip. The same if the facial nerve are the lateral canal (the nerve
exposed can be cauterized. Maceven’s triangle is runs 2.5 mm anterior to it). The best way to
identified. Aditus is supposed to lie just under identify the facial nerve is along the digastric
it about 1.5 cms deep. Drilling is begun in the ridge. When searching for mastoid segment of
area of Maceven’s triangle using a 8 mm cut- facial nerve a large diamond burr 5 mm should
ting burr. Large burr is always preferred in this be used. Ample irrigation should be used to
step. A very common mistake is to search for reduce thermal damage to the underlying nerve.
the antrum very low thereby endangering the Digastric ridge: This is the distal landmark of
facial nerve. The safest way to find the antrum is the mastoid segment of the facial nerve. It is a
to follow the dura. The tegmen tympani marks smooth convex bone found close to the mas-
the superior extent of the dissection. Drilling is toid tip. This ridge is difficult to find in a poorly
always begun above linea temporalis. The teg- pneumatized mastoid while it is easier to identi-
men tympani is exposed. It can be identified by fy in a well pneumatized one. Once the sigmoid
a change in the color of the bone and the change sinus has been skeletonized the digastric ridge
in the pitch of the burr. The dura should always is found by drilling inferior to the sinus close
be skeletonized till the middle cranial fossa dura to its mastoid tip from laterally to medially in a
is exposed and is seen shining through a thin horizontal direction. The periosteal fibers run
layer of bone. The dural plate is followed in an anteriorly from the digastric ridge in a perpen-
anteromedial direction. The lateral semicircular dicular plane to the ridge. The facial nerve can
canal is encountered next. As soon as the later- be located proximal to the stylomastoid foramen
al canal is visualized the direction of drilling is by drilling the last of these periosteal fibers. The
changed to a medial to lateral action in order surgeon could encounter the sensory branch of
to avoid touching the ossicles. If ossicles are the facial nerve which innervates the posterior
touched by the rotating burr then it would cause canal wall just above the stylomastoid foramen.
sensorineural hearing loss. The body and short The nerve is skeletonized by drilling in a wide
process of incus are identified next. The incus plane between the lateral canal proximally and
is often seen by its refraction in the irrigation the stylomastoid foramen distally working from
fluid. Medial to the incus the tympanic segment anterior to posteriorly. Drilling is always done
of the facial nerve is identified. The sinodural parallel to the course of the facial nerve. Lots of

Surgical techniques in Otolaryngology

34
irrigation should be done. Drilling should be while drilling in this area. The tympanic and
performed along the lateral aspect of the nerve. labyrinthine segments including geniculum lie
Drilling should not be done behind and medial in this area. The tympanic segment lies in the
to the fallopian canal. Once the facial nerve is floor of the anterior epitympanic recess. Nerve is
identified the retrofacial cells can be exenterat- supposed to lie above the cochleariform process
ed. Posterior tympanotomy: The facial nerve is which is a reliable landmark. The cog which is
skeletonized leaving a thin shelf of bone overly- a bony process in the anterior epitympanum
ing the nerve. It is followed proximally towards which extends from the tegmen tympani points
its pyramidal segment, just inferior to the lateral to the location of the facial nerve.
canal. The facial recess is approached by drilling
away the bone situated between the pyramidal
segment of the nerve posteriorly, the chorda Modified radical Mastoidectomy:
tympani and the fossa incudis superiorly. In the
absence of disease, the facial recess and stapes This procedure is performed in patients with
suprastructure is visible through the tympa- extensive cholesteatoma and in whom follow up
notomy. For removal of cholesteatoma in facial is suspected not to be regular. Hence given the
recess one has to work from both sides of the only chance to tackle the disease the surgeon
intact posterior canal wall. Epitympanotomy: should perform complete removal of the disease
If cholesteatoma does not extend significantly in the first chance itself. The procedure is the
into the attic then atticotomy is performed. This same for atticotomy. The difference being the
involves exposure of the head of the malleus and posterior canal wall is lowered up to the level of
the incus to remove soft tissue from attic. The the facial canal. The aditus, antrum and the en-
outer attic wall is removed, by drilling using a tire middle ear cavity is exteriorized as a single
diamond burr. While drilling in this area care large cavity. A meatoplasty should be performed
should be taken to ensure that the burr does not in these patients. The meatoplasty creates a large
touch the ossicles. The tegmen plate should not opening in the external ear that would commu-
be breached. nicate with the operated cavity.

Epitympanectomy: The operated cavity and the meatoplasty are

packed with ointment gauze. The wound is
This procedure is indicated when cholesteatoma closed in layers.
extends medial to the ossicles or overlies the
lateral canal. If ossicles are involved by choleste- Drilling tips:
atoma then the ossicles need to be removed. The
incus is removed by mobilizing it with a 45-de- 1. It is better to set the magnification of the mi-
gree hook without injuring the underlying facial croscope between 4 - 6X as this will give a more
nerve. The malleus head is severed with a mal- complete orientation of the drilling area. Higher
leus clipper. The head of the malleus is removed magnification levels are necessary to appreciate
leaving the tensor tympani tendon intact. Facial the minute details.
nerve lies in this area. It should not be damaged

Prof Dr Balasubramanian Thiagarajan

2. It is best to choose the largest possible burr bit as it will prevent damage to the structure even if
for initial drilling as this will cause less damage. the hand piece slips.
Using small burrs is always dangerous.
13. Canalplasty should be performed whenever a
3. The length of the cutting burr is adjusted bony overhang obscures complete visualization
according to the depth of the area to be drilled. of the ear drum.
Shorter the burr length better is the control.
14. while drilling care should be taken not to
4. Majority of bone drilling should be performed touch the ossicular chain.
by using cutting burrs. Diamond burrs can be
used when drilling is to be performed over facial 15. Middle cranial fossa dural plate should not
nerve area, dura, sigmoid sinus or sometimes to be drilled as this could cause CSF Otorrhoea.
obtain hemostasis over bleeding from bone.
Mastoidectomy Various Types
5. The hand piece should be held like a pen.
Different types of Mastoidectomy procedures
6. Drilling should be performed in a tangential have been described in the
direction as the cutting surface of the burr is literature. In this article we are making every
present in its sides. effort to clear the air and put to rest the con-
fusion which has been reigning so for. Several
7. The tip of the burr bit should not be used for basic terms, such as atticotomy, attico antrosto-
drilling. my, simple Mastoidectomy, conservative radical
operation, classic radical operation and tympa-
8. Only minimal pressure should be exerted over nomastoidectomy have often been described.
burr bits during drilling.
Atticotomy:
9. For fine drilling the head of the patient should
always be supported. Otherwise also known as Epitympanotomy,
denotes opening of the attic, performed through
10. The direction of rotation of burr should the transmeatal route. In this procedure the
always be away when drilling over important lateral wall of the attic is drilled away and the
structures. (Reverse). lateral attic is exposed.

11. Liberal irrigation should be performed

during the whole of the drilling process. This is
more important when drilling is performed over
facial nerve area / labyrinth.

12. It will be prudent to place the suction tip

between the burr bit and an important structure

Surgical techniques in Otolaryngology

36
Image showing atticotomy with preservation of Image showing Atticotomy with total removal
outer attic wall / bony bridge of bony bridge

Atticotomy can be performed in several ways, 2. Total removal of the bony bridge together
leading on to various modifications: with the lateral attic wall up to the level of teg-
men tympani, exposing the lateral attic, the ossi-
cles and the ligaments as shown in fig 2. In cases
of resorption of the ossicles or removal of the
1. Preservation of the bony bridge, by drilling remnants of the ossicles, the atticotomy can be
superior to the bony annulus and widening it further extended and the medial attic exposed.
towards the tegmen tympani. This is shown in 3. In cases of resorption of the ossicles or remov-
the illustration above. al of the remnants of the ossicles, the atticotomy
can be further extended and the medial attic
exposed.

Prof Dr Balasubramanian Thiagarajan

 Image showing atticotomy with a partially
Image showing medial attic wall exposed due removed bony bridge
to erosion of head of the malleus and body of
incus. 5. The bridge can be removed or be resorbed in
the middle as shown in the figure above.

4. Partial removal of the bony bridge. This situ-

ation can be caused by spontaneous resorption
of the bony annulus by cholesteatoma; or by
drilling in cases in which there are difficulties in
removing cholesteatoma at a particular point; or
lastly in cases with fixation of malleus.

Image showing Atticotomy with removal of

anterior part of bony ridge

Surgical techniques in Otolaryngology

38
 superolaterally than the original bridge. This
6. In attic cholesteatoma there is often resorp- type of displacement of the bridge occurs after
tion of the bone in the region of Sharpnells’s performing an anterior attico-tympanotomy in
membrane (the scutum), and the bridge cannot order to remove the tensor tympani fold and the
remain intact in its middle or anterior part. bony plate in the anterior attic to improve the
ventilation through it.
7. In sinus cholesteatoma, starting with a pos-
terosuperior retraction of pars tensa, the poste-
rior part of the bridge can be resorbed, or may
have been removed to gain better access to this
region.

Image showing Atticotomy with superolateral

displacement of an intact bridge

Even though methods involving removal of the

bridge have been popular it is always better to
preserve varying amounts of bridge in order to
Image showing Atticotomy with removal of maintain the middle ear space. Of course, sacri-
posterior part of bony bridge ficing the bridge saves lot of time during surgery.

8. Displacement of the intact bridge - In cas- Attico antrostomy:

es with attic cholesteatoma and spontaneous
resorption of the bridge, or in cases requiring Is nothing but an extension of the atticotomy
drilling of the bony annulus in order to provide in a posterior direction through the transme-
better exposure of the mesotympanum, part atal route. The lateral attic and aditus walls are
of the superior bony annulus (the scutum) is removed, and the antrum is entered. The pos-
drilled away, displacing it superiorly. After the terosuperior bony can wall is removed, and the
atticotomy, the new bridge is positioned more access to the antrum is gradually widened. In

Prof Dr Balasubramanian Thiagarajan

cases with poor pneumatization, a small antrum,
and a sclerotic mastoid process, an attico antros- Bondy’s Operation:
tomy results in a small cavity with smooth walls.
In a large cell system, the attico antrostomy This is nothing but attico antrostomy without
results in a large cavity. entering the tympanic cavity. The lateral part of
the cholesteatoma matrix is removed; the medial
part is left in place marsupializing the cholestea-
toma. If the tympanic cavity is entered the oper-
ation is not described as Bondy’s operation, but
as an attico antrostomy or conservative radical
operation.

In classic Bondy’s operation attico antrostomy

removal of the posterosuperior bony meatal
wall is performed exposing the cholesteatoma
sac involving the attic and antrum. The sac is
then incised, a suction tube is placed in the sac,
and the cholesteatoma mass is sucked away. The
lateral part of the matrix is then cut off.

If the tympanic cavity is opened and the choles-

teatoma marsupialized with the
Image showing a large attico antrostomy matrix being left in place in the attic, the fascia
has to be placed under the matrix in order to
prevent in growth of the cholesteatoma into
the tympanic cavity. The keratinized squamous
epithelium of the matrix and the epithelium of
the replaced drum remnant and the canal skin
gets integrated.

Image showing a small attico antrostomy

Surgical techniques in Otolaryngology

40
 Image showing Bondy’s operation

If there is no need for hearing improvement Image showing attico antrostomy, or conserva-
and ossiculoplasty, the tympanic cavity is not tive radical operation, with marsupialization
opened in Bondy’s operation, whereas in conser- of an attic cholesteatoma extending into the
vative attico antrostomy a tympanoplasty is also tympanic cavity, which is open. The sac is in-
performed, either to prevent in growth of the cised, and the cholesteatoma is sucked out. The
cholesteatoma into the tympanic cavity or as a tympanic cavity is entered, with the tympano-
part of ossiculoplasty. meatal flap being elevated posteriorly.

In the treatment of attic cholesteatoma, a grad-

ual transition from an atticotomy with removal
of the bony bridge to Bondy’s operation can be
seen. In fact, it is only the extent of bone remov-
al from the posterosuperior ear canal wall and
the adherence of the cholesteatoma membrane
to the lateral semicircular canal, with blockage
of the ventilation through the tympanic isth-
mus that distinguishes a large atticotomy from
a small Bondy’s operation. In both types, the
medial part of the cholesteatoma sac is left in

Prof Dr Balasubramanian Thiagarajan

place covering the intact Ossicular chain, or the
medial wall of the aditus ad antrum with the
lateral semicircular canal and the medial wall of
the antrum.

Image showing incus interposition between the

stapes and the malleus handle, after placement
of the fascia under the epithelial edges and un-
der the drum, and after replacement of the skin
flaps, the conservative operation is completed.

Image after removal of the partly eroded incus,

and after resection of the head of the malleus,
the medial part of the cholesteatoma matrix is
left in place. The cholesteatoma is marsupial-
ized in the attic and antrum regions but re-
moved from the tympanic cavity.

Image showing the side view of an atticotomy

with removal of the scutum and the bony bridge
(hatched area)

Surgical techniques in Otolaryngology

42
In cases with a small attic cholesteatoma, good
hearing, and no significant discharge, and in
which the bottom of the cholesteatoma cannot
be seen, an atticotomy can be performed by
removing the scutum until the bottom is visi-
ble. The lateral wall of the cholesteatoma sac is
removed, and the medial wall is left in place,
improving access to the cholesteatoma sac and
facilitating migration of the keratin from the sac.
In an attic cholesteatoma involving the aditus ad
antrum, a large part of the postero superior bony
canal must be drilled in order to perform a large
atticotomy and marsupialize the cholesteatoma.
Ventilation of the antrum still occurs through
the tympanic isthmus under the body of incus
and the head of the malleus and under the medi-
al part of the cholesteatoma matrix, which is not
yet adherent to the lateral semicircular canal.
The adherence of cholesteatoma membrane to Image showing side view of a large atticotomy
the lateral semicircular canal is probably the or a small Bondy’s operation in an attic choles-
most reliable sign differentiating the atticoto- teatoma involving the aditus ad antrum, ad-
my from the Bondy’s operation in cases of attic herent to the lateral canal closing the isthmus,
cholesteatoma. In cases with adherence of the blocking the ventilation of the antrum. Even
cholesteatoma membrane to the lateral canal the after removal of the large part of the superior
aditus ad antrum is involved in the cholesteato- bony canal wall (hatched area) and the lateral
ma, and ventilation of the antrum cannot take membrane of the cholesteatoma sac (dashed
place through the tympanic isthmus. Extensive line) with good exposure of the medial choles-
removal of bone is necessary to visualize the teatoma wall, progression of the cholesteatoma
cholesteatoma sac, and the result resembles a is possible towards the antrum indicated by the
small open attico antrostomy cavity – a Bondy’s arrow.
operation.

Prof Dr Balasubramanian Thiagarajan

 Image showing side view of a Bondy’s operation
in a case with large attic cholesteatoma. All
bone from the postero superior canal wall up
to the middle fossa dura is removed (hatched
area), together with the lateral membrane of the
cholesteatoma sac. The cholesteatoma is mar-
supialized, with wide access to the small open
cavity. The Ossicular chain is intact, and the
medial cholesteatoma membrane is adherent to
the medial aditus and antrum walls.

operation. The only difference between this

Cortical Mastoidectomy (Schwartz Mastoid- and the attico antrostomy is the extent of bone
ectomy) removal. In the radical operation, the exenter-
ation of the air cells is more radical than in an
This is a transcortical opening of the mastoid attico antrostomy. Also, marsupialization of
cells and the antrum. It is the initial stage of any the cholesteatoma and leaving intact the medi-
Transmastoid surgery of the middle ear, inner al part of the cholesteatoma membrane is not
ear, facial nerve, endolymphatic sac, labyrinth, included in conservative radical operation.
internal acoustic meatus, and various proce-
dures on the skull base for removing skull base DEFINITIONS:
tumors.
BRIDGE: is a part of bony postero superior
Conservative Radical Operation meatal wall lateral to aditus ad antrum.
Facial Ridge: It is a bony posterior meatal wall
Conservative radical Mastoidectomy, conser- that lies lateral to vertical portion of facial
vative radical operation, or modified radical nerve. Anterior Buttress: is that part of the bone
operation is a canal wall down procedure, where the posterior canal wall meets the teg-
denoting a Mastoidectomy with opening of men.
the antrum and attic, removal of the postero Posterior Buttress: is that part of the bone
superior bony canal wall, either drilling away of where posterior canal wall meets the floor of
the bony bridge and lowering of the facial ridge the external auditory canal lateral to the facial
or preserving the thinned down bony ridge. nerve.
The structures within the tympanic cavity are
preserved, hence the term conservative radical

Surgical techniques in Otolaryngology

44
 Image showing simple cortical Mastoidectomy in a retro auricular approach. The antrum and
the mastoid cells are opened. The bony meatal wall is intact but thick, because the small cells
of the ear canal have not been removed. The lateral canal, the malleus, and the incus are just
visible. The outer attic wall is not opened.

tympanic cavity, an attempt to close the tympan-

Classical Radical Operation: ic cavity is performed to achieve faster healing,
or sometimes even to reventilate the tympanic
Classical radical Mastoidectomy or classical rad- cavity, or at least a part of it.
ical operation is a canal down Mastoidectomy
and includes the same bone work in the mastoid
process as the conservative radical operation.
However, the structures within the tympanic
cavity are removed, e.g. the remnants of the in-
cus and malleus, and the drum remnant with the
fibrous annulus and sometimes even the bony
annulus. In a classical radical operation closure
of the eustachean tube is performed. Today even
after radical removal of all structures from the

Prof Dr Balasubramanian Thiagarajan

 Tympanomastoidectomy:

Transmastoid tympanoplasty, tympanomastoid-

ectomy, combined approach tympanoplasty or
cortical Mastoidectomy, are terms denoting an
intact canal wall or canal wall up Mastoidectomy
where the posterior canal wall is preserved. The
procedure is based on retro auricular approach.

Several methods of Mastoidectomy are used:

1. classic intact canal wall

2. Modifications of intact canal wall procedures,
3. Temporary displacement or removal of bony
Image showing the Bridge ear canal.

Approaches and Routes:

The term approach means the method of access

to the middle ear through soft tissues: the term
route means the method of access to the mid-
dle ear through the bone. The approaches can
be Endaural, or retro auricular, and superior
or anterior. The routes can be transcortical or
transmeatal.

Transcortical route:

The transcortical route for drilling starts on

the surface of the cortical bone of the mastoid
process, behind the bony ear canal, which can
Image showing the situation in the tympanic remain intact either temporarily or permanent-
cavity after a classical radical Mastoidectomy ly. This route is also described as the outside
with removal of the fibrous annulus and all os- in route, because the initial drilling is always
sicles. The cavity is large, the facial ridge is low. outside.

Surgical techniques in Otolaryngology

46
Transmeatal route:
Approaches and mastoidectomies:
The transmeatal (trans canal) route for drilling
starts in the bone of the ear canal, either later- In Mastoidectomy, both the Endaural and the
ally or medially. This route is also described as retro auricular approaches have various advan-
the inside out route, because the initial drilling tages and disadvantages.
is from within the ear canal, e.g., with an atti- 1. The view into the attic in the retro auricu-
cotomy followed by antrostomy and retrograde lar approach is oblique, in the posteroanterior
Mastoidectomy. Through this Endaural route, an direction. In the Endaural approach, the view
atticotomy alone without Mastoidectomy can be is direct, lateromedially, and the distance to the
performed. The Mastoidectomy can start in the attic is shorter than in the retro auricular ap-
ear canal, as in the transcortical route. proach.
2. The view into the Eustachian tube orifice is
good in both approaches, but somewhat better
in the retro auricular approach.
3. The view into the posterior tympanum and
sinus tympani is better in the Endaural than in
the retro auricular approach.
4. Mastoidectomy can easily be extended in the
retro auricular approach, whereas extension
is difficult or even impossible in the Endaural
approach.
5. Cavity obliteration with muscle flaps, espe-
cially using the anterior based Palva flap and the
inferiorly pedicled Guilford flap are only possi-
ble in the retro auricular approach

The retro auricular approach is increasingly

Image showing transcortical and transmeatal dominating mastoid surgery, partly because of
routes for a Mastoidectomy in the retro auric- the ease of cavity obliteration and better access it
ular approach. The ear canal skin is pushed provides.
anteriorly, and its superior part is elevated. The
bone work can be performed by a transcortical Routes and approaches:
(outside - in) route or a transmeatal one (inside
- out). The transcortical TC and transmeatal Using the retro auricular approach, both the
TM routes are indicated as well as the transme- transcortical and the transmeatal routes to the
atal routes for atticotomy A, attico antrostomy mastoid for canal wall up Mastoidectomy, attico
AA and Mastoidectomy M. The dark dotted antrostomy, and canal wall down Mastoidecto-
area is the sigmoid sinus. my can be used. In fact, the transmeatal route
can be employed as easily as the transcortical

Prof Dr Balasubramanian Thiagarajan

route. With the Endaural approach, the Trans-
meatal route is the route of choice.

An atticotomy usually starts with drilling of the

lateral attic wall, and a transmeatal attico an-
trostomy follows the atticotomy through further
drilling of the ear canal wall. Mastoidectomy
or a conservative radical operation can then be
performed as a retrograde extension of the attico
antrostomy. The cavities produced using the
retro auricular approach, either by transcortical
or the transmeatal route, are generally larger
than the cavities produced using the Endaural
approach.

Image showing the cavity usually achieved in

an end aural approach with less extensive drill-
ing of the cortical bone at the mastoid plane.

Canal wall up and canal wall down mastoidec-

tomies:

The terms canal wall up and canal wall down

have become popular. Mastoidectomies are
classified exclusively based on whether the canal
wall is removed or remains intact. The fact that
the bony ear canal wall sometimes remains only
partly intact, e.g., after spontaneous erosion, or
is deliberately partly removed, results in sever-
al variations or modifications of the canal wall
Image showing side view of the mastoid cavity Mastoidectomy techniques.
obtained in a retro auricular approach with ex-
tensive drilling of the cortical bone at the mas- Sub-classification of, or synonyms for canal wall
toid plane. Medially, the lateral semicircular down Mastoidectomy techniques are: atticoto-
canal, facial nerve, stapes and malleus handle, my, Bondy’s operation, attico antrostomy, classi-
with the anterior aspect of the drum are shown. cal radical operation, retrograde Mastoidectomy.

Surgical techniques in Otolaryngology

48
The subclassifications of canal wall up tech- several so called intact canal wall methods, the
niques are simple Mastoidectomy, cortical bony ear canal is not intact at all, partly because
Mastoidectomy, classic intact canal wall Mas- of the extensive drilling of the medial ear canal
toidectomy, CAT. The other features of the wall, and partly because of the spontaneous
classification are the obliteration of the cavity or resorption of the lateral attic wall.
reconstruction of the ear canal or both.
Modifications of intact canal wall Mastoidec-
Open technique: tomy:

In canal wall down Mastoidectomy, the cavity 1. Atticotomy with preservation of the intact
may remain open, neither obliterated nor with bony bridge
the ear canal reconstructed. The exposed bone is 2. Atticotomy with preservation of a partly re-
simply covered with fascia or skin or not cov- sorbed bony bridge
ered at all. This type of cavity is lined by granula- 3. Atticotomy with removal of the bridge
tions and later re epithelialized. 4. Widening of the ear canal Atticotomy open-
ings of various sizes with preservation of the
Closed technique: intact non resorbed bony bridge: The goal of
this atticotomy is to obtain a good view into the
The canal wall down Mastoidectomy cavity anterior attic. The bridge remains in its normal
can be partly or totally obliterated, and the ear position.
canal partly or totally reconstructed. A partly or
totally reconstructed canal wall down cavity is Atticotomy openings of various sizes with
defined as the closed technique. preservation of a partly resorbed bony bridge:

Classic canal wall up Mastoidectomy: In cases in which there is spontaneous re-

sorption of the lateral attic wall due to choles-
Also known as classic intact canal wall Mastoid- teatoma, an atticotomy has to be performed
ectomy or CAT is defined as a Mastoidectomy superiorly to the resorbed bridge, resulting in
with an entirely preserved, but thinned, bony ear displacement of the new bridge superiorly and
canal wall. The disease from the attic is removed laterally. Sometimes, resorption of the lateral
through careful drilling of all the bone between wall can be more extensive, so that the atticoto-
the ear canal and the tegmen tympani and hence my has to be performed further laterally, and the
enlarging access to the attic. Access to the tym- bony bridge in such cases is displaced further
panic cavity is achieved by a so called posterior superolaterally.
tympanotomy otherwise also known as poste-
rior attico-tympanotomy. The goal of the intact Atticotomy openings of various sizes with
canal wall Mastoidectomy is to re pneumatized removal of bony bridge:
the mastoid cavity.
Several modifications of intact canal wall Mas- Removal of the lateral attic wall is known as
toidectomy have been described and used, but in anterior tympanotomy. In cases with resorption

Prof Dr Balasubramanian Thiagarajan

of the lateral attic wall, only limited removal of
the bridge is necessary. After extensive removal
of the lateral attic wall and a large atticotomy,
only the lateral half of the ear canal wall is intact.
Widening of the ear canal: By drilling the lateral
part of the canal, better access to the tympanic
cavity can be achieved. The superior wall of the
ear canal can be drilled away, exposing the later-
al attic, the tegmen antri, and the tegmen tym-
pani. With continued drilling of the ear canal,
an attico antrostomy can be performed resulting
in the entire canal wall being displaced posteri-
orly in relation to its normal position, with the
attic being exposed. The bridge can be preserved
or removed. Usually the Ossicular chain is not
intact.

Canal wall down Mastoidectomy:

The canal wall down mastoidectomies include Image showing Canal wall down Mastoidec-
attico antrostomy, Bondy’s operation and con- tomy with preservation of the bridge in a case
servative and classic radical mastoidectomies with spontaneous erosion of the lateral attic
with total removal of bony bridge. Modifications wall, resulting in the bridge being displaced
of canal wall down Mastoidectomy: Modifica- laterally and posteriorly.
tions are related to the preservation or partial
preservation of the bony bridge, resulting in in-
tact bridge techniques. In cases with resorption
of the lateral attic wall, the bridge can be pre-
served, but is displaced laterally and posteriorly.
The bridge may be partly resorbed, or surgi-
cally removed either posteriorly or anteriorly.
In combination with various degrees of Ossic-
ular deficiency (e.g., missing incus but present
malleus, or missing incus and malleus head)
and various types of partial bridge removal have
been described.

Surgical techniques in Otolaryngology

50
 Image showing Canal wall down Mastoidec-
tomy with preservation of the bridge, which is Image of the ear canal with atticotomy and
displaced laterally and posteriorly in relation to Mastoidectomy, without bridge preservation.
the incus and malleus.

Cortical Mastoidectomy

Introduction:

This procedure is also known as simple mastoid-

ectomy / complete mastoidectomy. This proce-
dure consists of opening the mastoid cortex and
identifying the aditus and antrum. A complete
mastoidectomy involves removal of mastoid air
cells along tegmen, sigmoid sinus, presigmoid
dural plate, and posterior wall of the external
auditory canal. In this procedure the posteri-
or wall of the bony external auditory canal is
preserved. It is only thinned out in order to get
Image showing Canal wall down Mastoidecto- better access to all these air cells.
my with partial preservation of the bridge in a Successful and complication free mastoid sur-
case with partial preservation of the bridge in a gery is only possible if the following critical
case with spontaneous resorption of the bridge. structures are identified. These identified vital

Prof Dr Balasubramanian Thiagarajan

structures should not be fully exposed and a
thin layer of cortical bone should be allowed to Position:
cover them. Allowing a thin bony covering over
them prevents complications from occurring The patient is placed in supine position with the
due to injury of these structures. To identify head turned to the opposite side. The face is
these structures adequate magnification is a supported by keeping a small sandbag under the
must. Hence operating microscope is a necessi- face on the opposite side.
ty for all mastoid surgical procedures.
Incision:
Indication:
Post aural incision of William Wilde is used.
1. Chronic otitis media not responding to con-
ventional medical management 2. Chronic otitis
media with cholesteatoma. Mastoidectomy
provides access to remove cholesteatoma matrix
from areas that are difficult to visualize through
the external auditory canal. These areas include:
Supra tubal recess, epitympanum, facial recess,
peri labyrinthine air cells, retrofacial air cells. 3.
Mastoidectomy is an initial step for cochlear im-
plant procedures 4. Mastoidectomy is the initial
step in removal of lateral skull base neoplasms
like vestibular schwannomas, meningiomas,
glomus tumors and epidermoids.

Contraindications:

1. If the patient is medically unfit to undergo the Image showing post aural incision of William
surgery Wilde
2. Patients with poorly pneumatized mastoid
may make the procedure a little complex as the Sir William Wilde who popularized this inci-
vital landmarks are difficult to identify. sion as a treatment of mastoiditis is the father of
Oscar wilde. He was the first to teach otology
Anesthesia: in the United Kingdom. This incision is used
for exposing the mastoid process. It follows the
Ideally mastoidectomy is performed under post aural fold. It begins just above the upper
general anesthesia. Endotracheal tube is used to attachment of auricle, and it extends downwards
maintain the airway and to administer anesthet- to the tip of the mastoid.
ic gases and oxygen. The mastoid process in infants is not fully devel-
oped, the usual incision could injure the facial

Surgical techniques in Otolaryngology

52
nerve. In this age group the incision should be
placed more horizontally.

A – Adult post aural incision

B – Post aural incision in a child
Diagram representing Endaural incision
Advantages of post aural incision:

This incision provides wide and open exposure.

This facilitates thorough exenteration of mastoid
air cells. It also provides an access for unexpect-
ed extension of disease process and also helps in
dealing with complications of mastoiditis.

Endaural incision of Lempert:

The incision is made in the cartilage free area

filled with fibrous tissue (incisura terminalis).
The incision is extended upwards parallel to the
helix. The lower part of the incision is made at
the bony cartilaginous junction and is curved Image showing Lempert’s speculum being used
from 3 - o clock position in the canal through to expose incisura terminalis area
the 12-o clock position to reach the floor of the
canal at 6 - o clock position. The incision is
deepened through the periosteum which is sepa-
rated upwards and backwards exposing the bony
mastoid cortex.

Prof Dr Balasubramanian Thiagarajan

 This incision provides direct access to the exter-
nal osseous canal, ear drum and tympanic cavity.
Since the exposure is limited this incision can be
used in limited middle ear disease.

Infiltration:

The post aural area is infiltrated with 1% xy-

locaine with 1 in 100,000 adrenaline. This
infiltration ensures that skin and is lifted away
from the mastoid bone. Presence of adrenaline
reduces bleeding during surgery.

The operating microscope with 200-250 mm ob-

Image showing incision given in the incisura jective is used for the entire procedure. Cutting
terminalis area and diamond burrs of various sizes are used.

A curvilinear post aural incision starting from

the linea temporalis up to the level of mastoid
tip. The incision should be sited 5-10 mm poste-
rior to the post aural sulcus. Incision should
avoid post aural sulcus as it would enter the ex-
ternal auditory canal. 15 blade knife is used for
making the incision. The skin and subcutane-
ous tissue is elevated off the periosteal lining of
the mastoid bone until the bony portion of the
external auditory canal can be palpated through
the periosteum.

After exposing the periosteum an incision is

made along the linea temporalis from the root
Image showing Incisura terminalis incision of the zygoma to the occipito mastoid suture
seen being deepened line. A perpendicular periosteal incision is
made from the linea temporalis to the mastoid
tip. The periosteum is elevated off the mastoid
cortex up to the bony portion of the external
auditory canal. This is an anterior based perios-
teal flap. A retractor is used to hold the auricle
forward.

Surgical techniques in Otolaryngology

54
 found centered over the cribriform area of the
mastoid cortex which is just located posterior
and superior to the osseous external meatus.

Image showing mastoid cortex after periosteum

is elevated Image showing the direction of initial bone cuts

Operating microscope with a 200-250 mm

focal lens is used during bone drilling. Drilling
should commence at the level of and parallel
to the linea temporalis. Largest sized burr bit
5/8mm is used for this purpose. Copious irriga-
tion of saline should be given to prevent thermal
injury to the underlying structures. Drilling is
continued till the temporal lobe dura (tegmen)
is covered only by a thin osseous lining. Next
the burr is used to drill curvilinearly from the
sinodural angle to the mastoid tip. The sigmoid
sinus should be identified while drilling from
the mastoid tip area to the posterior aspect of
the tegmen. The sigmoid sinus can be seen as Image showing the mastoid bowl after initial
a blue tinge. A thin bony lining should be left phase of drilling
over the sigmoid sinus in order to protect the
sinus. Air cells along the posterior aspect of the
external auditory canal are removed until the
cortical bone is identified. The aditus would be

Prof Dr Balasubramanian Thiagarajan

 Image showing the anatomy after complete
mastoidectomy
Image showing mastoid air cells

The perifacial cells are drilled and opened out.

This drilling creates a mastoid bowl. The pos- Aditus is widened.
terior canal wall should be drilled in such a way This procedure ensures that the mastoid air cells
that it loses its curvature and becomes straight. are exenterated and the middle ear ventilated.
It should be thinned progressively till the instru- The aditus block is removed by widening the
ment placed in the external canal is seen as a aditus.
shadow from the mastoid bowl. Aditus anatom- The external canal is packed with ointment im-
ically lies 1.5 cm underneath the Henle’s spine. pregnated gauze.
Entry into the aditus will be revealed by the The wound is closed in layers and mastoid dress-
change in the sound of the drilling burr bit. The ing is applied.
lateral canal is identified along the medial sur-
face of the aditus ad antrum. The otic capsule
bone covering the lumen of semicircular canal is
yellow and is always of different color from that
of the adjacent bone. The lateral semicircular
canal is a critical landmark in mastoid surgery
because since the second genu of facial nerve is
always inferior to the midpoint of the canal.

Surgical techniques in Otolaryngology

56
 3. Micro ear instruments
Modified radical mastoidectomy
Anesthesia:
This is the operative technique used to manage
cholesteatoma. In this procedure all diseased This surgery can be performed either under
tympanomastoid air cells are removed, exenter- local / General anesthesia
ated and exteriorized to the external auditory
canal. The middle ear transformer mechanism Anatomical landmarks:
is reconstructed.
1. Temporal line
Indications:
2. Henle spine
1. Cholesteatoma
3. Mastoid tip
2. CSOM with extensive middle ear granulation
4. External auditory canal
Steps of modified radical mastoidectomy:
MacEven’s triangle:
1. Drilling the mastoid cortex
This triangle contains the spine of Henle. It also
2. Exenterating mastoid air cells serves as an important landmark for mastoid an-
trum as it lies 1.2 - 1.5 mm deep to this triangle.
3. Identification of aditus
Boundaries:
4. Widening the aditus
Superior - Temporal line
5. Removal of outer attic wall (bridge)
Anterior - Postero-superior margin of bony por-
6. Lowering the facial ridge up to the level of the tion of external auditory canal
lateral canal
Posterior - Is formed by a tangential line draw to
7. Performing a meatoplasty mid point of posterior wall of external canal

Equipment needed:

1. Operating microscope with 200-250 mm ob-

jective is used for the entire duration

2. Otological drill with burr bits of different sizes

Prof Dr Balasubramanian Thiagarajan

 the incision is being made.

The skin and subcutaneous flap is elevated until

the bony portion of the external canal can be
palpated through the periosteum. Once the
periosteum is exposed, an incision is made along
the linea temporalis from the root of the zygoma
to the occipito mastoid suture. Another perpen-
dicular periosteal incison is made from the linea
temporalis to the tip of the mastoid process. The
periosteum is elevated off the mastoid cortex up
to the level of the external auditory canal using a
periosteal elevator. A retractor is then placed to
hold the auricle forward.

An operating microscope with 200-250 mm

focal length lens is used from now on. Ideally
Image showing McEven’s triangle drilling should be done under microscopic vi-
sion. The microscope provides good magnified
visualization at the expense of a narrower field
Positioning: of vision. Drilling commences at the level and
parallel to linea temporalis. Copious suction
Patient is placed in a supine position with the irrigation should be performed to remove bone
head rotated about 30-45 degrees away from the dust. Irrigation also prevents thermal injury to
surgeon. The patient’s head should be placed as the bone and underlying structures. Identifica-
close to the edge of the table as possible. tion of temporal lobe dura (tegmen) leaving a
very thin bone covering over it is the initial step
Incision: of mastoid surgery. After identification of dura
is made, the sigmoid sinus can be identified and
Post auricular area is infiltrated with 2% xylo- exposed by drilling from the mastoid tip area to
caine with 1 in 100,000 adrenaline. Infiltration the posterior aspect of tegmen. The sigmoid si-
helps in reduction of bleeding and also in flap nus can be identified by its characteristic bluish
elevation. Post aural incision of William Wilde tinge.
is used. This is a curvilinear starting from linea
temporalis superiorly to the mastoid tip. This Air cells along the posterior aspect of the ex-
incision should be as close to the post aural ternal auditory canal are removed until cortical
sulcus as possible. Caution should be exercised, bone is identified. The aditus ad antrum situ-
and the incision should not enter the external ated just under the cribriform area of mastoid
auditory canal. This can be avoided by placing cortex should be entered. As the aditus is wid-
the left index finger over the external canal while ened the dome of lateral canal comes into view.

Surgical techniques in Otolaryngology

58
It can be seen as whitish part of bone. Lateral performed.
canal is the critical landmark in mastoid surgery.
The second genu of the facial nerve lies inferior
to the midpoint of the lateral canal. Mastoid
portion of facial nerve can be skeletonized once
the lateral canal has been identified. The facial
nerve typically courses in a more lateral and an-
terior portion in its course from the second genu
to the stylomastoid foramen. The zygomatic
root cells lying superior to the osseous external
canal, adjacent to the glenoid fossa are opened
in patients with extensive cholesteatoma in the
epitympanum / supratubal recess.

The middle ear can be visualized by opening the

facial recess. The facial recess is defined by the
mastoid portion of facial nerve, chorda tympani
nerve and incus buttress. The incus buttress is
a bridge of bone connecting the lateral canal to Image showing facial recess
the medial aspect of the osseous posterior supe-
rior external auditory canal. The short process
of incus is attached to the incus buttress with
a small ligament. Opening of the facial recess
provides excellent visualization of the oval and
round windows. The anterior aspect of the sinus
tympani, hypotympanum and protympanum
can also be visualized. Facial recess is opened
usually during cochlear implant surgery. Open-
ing up this recess is beneficial in cholesteatoma
surgery as it allows the surgeon to remove dis-
ease from the region under direct visualization.

In modified radical mastoidectomy, the posteri-

or canal wall is thinned out. Outer attic wall is
removed, the anterior and posterior buttresses
are also removed. Facial ridge is reduced till Image showing cholesteatoma in MRM cavity
the level of lateral canal is reached. This results
in a single cavity that includes mastoid cavity,
aditus, antrum and middle ear cavity. They are
made into a single cavity. A large meatoplasty is

Prof Dr Balasubramanian Thiagarajan

 Drilling tips:

1. It is better to set the magnification of the mi-

croscope between 4 - 6X as this will give a more
complete orientation of the drilling area. Higher
magnification levels are necessary to appreciate
the minute details.

2. It is best to choose the largest possible burr

bit for initial drilling as this will cause less dam-
age. Using small burrs is always dangerous.

3. The length of the cutting burr is adjusted

according to the depth of the area to be drilled.
Shorter the burr length better is the control.

4. Majority of bone drilling should be per-

formed by using cutting burrs. Diamond burrs
Image showing Cholesteatoma sac being re- can be used when drilling is to be performed
moved from attic area over facial nerve area, dura, sigmoid sinus or
sometimes to obtain hemostasis over bleeding
from bone.
Burr bits:
5. The hand piece should be held like a pen.
Burr bits comes in various sizes. A cutting burr
is made up of multiple blades more or less close 6. Drilling should be performed in a tangential
to each other. The greater the number of blades, direction as the cutting surface of the burr is
the more stable is the burr. More stable the burr, present in its sides.
the less well it cuts.
7. The tip of the burr bit should not be used for
Diamond burrs function by saucerising and drilling.
thinning the bone in contact. This burr is used
in proximity to or in contact with soft tissues 8. Only minimal pressure should be exerted
(dura, sigmoid sinus, and facial nerve). over burr bits during drilling.

Reverse cutting can be used to reduce the 9. For fine drilling the head of the patient
cutting power and also to avoid uncontrolled should always be supported.
movements that could make the burr to hit at
vital structures. 10. The direction of rotation of burr should
always be away when drilling over important

Surgical techniques in Otolaryngology

60
structures. (Reverse). nous (1/3) and medial bony (2/3) portions.
The medial bony portion of the external canal
11. Liberal irrigation should be performed consists of the tympanic bone which is a ringed
during the whole of the drilling process. This is lateral projection of temporal bone. There is a
more important when drilling is performed over notch in the superior portion of the tympanic
facial nerve area / labyrinth. bone known as the notch of Rivinus which is lo-
cated at the junction of tympanosquamous and
12. It will be prudent to place the suction tip tympanomastoid suture lines.
between the burr bit and an important structure
as it will prevent damage to the structure even if Sensory innervation of external auditory
the hand piece slips. canal:

13. Canalplasty should be performed whenever a 1. Auriculotemporal nerve (from the mandib-
bony overhang obscures complete visualization ular branch of the trigeminal nerve) provides
of the ear drum. sensory innervation to anterior, posterior walls
and the roof of external canal.
14. while drilling care should be taken not to 2. The posterior wall and floor of the canal is
touch the ossicular chain. supplied by the auricular branch of vagus (Ar-
nold nerve)
15. Middle cranial fossa dural plate should not 3. The tympanic plexus also supplies some areas
be drilled as this could cause CSF Otorrhoea. Blood supply:
1. Posterior auricular artery
Canalplasty 2. Deep auricular branch of the maxillary artery
3. Superficial temporal artery
Introduction:
Important anatomic relations that should be
A Canalplasty is usually performed to widen a borne in mind during surgery:
narrowed external auditory canal either due to Anterior to the bony portion of external audito-
congenital / acquired causes. The reasons for ry canal lie the temporomandibular joint and the
performing this procedure are as follows: parotid gland. During Canalplasty care should
1. To improve access to middle ear and mastoid be taken not to injure these structures. Posterior
cavities during mastoid surgeries and inferior to the bony external canal lies the
2. To remove bony / soft tissue growths / scar mastoid portion of the temporal bone and it
tissue occluding the external canal contains the facial nerve.
3. To treat aural atresia
Facial nerve courses usually lateral to the annu-
Anatomy: lus in the posteroinferior quadrant of the tym-
panic membrane.
The adult external auditory canal is about 2.5
cms long and is composed of lateral cartilagi- Function of external canal:

Prof Dr Balasubramanian Thiagarajan

 away from the anesthesiology team to allow
1. It serves as efficient conduit for transmission proper positioning of the microscope.
of sound from the environment to the ear drum
2. Protects the middle ear and inner ear from Approaches:
environmental insults
Indications: The following approaches are possible:
1. Hearing loss due to the presence of osteoma 1. Endo meatal
2. To improve self-cleansing mechanism of ex- 2. Post aural
ternal canal in the presence of exostosis 3. Endo meatal Typically a post aural approach
3. To improve visualization of ear drum while combined with Endaural incision is used to
performing tympanoplasty remove exostosis and medial canal fibrosis.
Contraindications:
1. Presence of acute infections in the external Endaural / endo meatal incision may be pre-
auditory canal ferred for osteoma as they often have a stalk
that facilitates easy removal. Endaural incision
Planning: is made in the external canal as far medial as
possible. A laterally based vascular strip is devel-
If otitis externa is present, then the patient oped in the external auditory canal skin. After
should be treated for the same by administration completion of this step the post aural incision is
of topical antibiotic ear drops. A combination of given. It is usually given 7 mm behind the post
antibiotic and steroid ear drops would actually aural sulcus. The incision is continued through
help. the auricularis posterior muscle down to tem-
poralis fascia. Periosteum over the mastoid is
Anesthesia: incised and elevated anteriorly to the external
canal. The Endaural incision is found from
This surgery is ideally performed under general the post aural approach, and the two incisions
anesthesia. In congenital external canal atresia are joined. The external auditory canal skin is
facial nerve monitoring is used and hence long carefully elevated off the bony external canal
acting paralytics should not be used. Xylocaine and then retracted forward with the auricle.
1% mixed with 1 in 100,000 adrenaline is used In external canal exostosis, the skin over the
to infiltrate the external canal. Infiltration is exostosis is elevated with a round knife and
usually given in the cartilaginous, hair bearing elevated toward the ear drum. The exostosis is
portion of the external canal. This is done to drilled down using a cutting / diamond burrs in
reduce bleeding during the procedure. a lateral to medial direction. Curettes can also
be used to dissect bony edges. Canalplasty for
Patient positioning: acquired external canal stenosis needs drilling of
the anterior bony canal. When drill is used care
The patient is ideally positioned supine on the should be taken to avoid contact with the ossic-
Operating table with the head turned away from ular chain as it could cause conductive hearing
the surgeon. The table is turned 180 degrees loss. While drilling anteriorly care should be

Surgical techniques in Otolaryngology

62
 taken to avoid penetration into the TM joint.
This can be prevented by drilling away bone
superior and inferior to the temporomandibular
joint first, before carefully removing the buttress
of bone overlying the joint. After canaplasty
the skin flap is repositioned, and the wound is
closed in layers. Ideally a stent may be placed to
assist adherence of the external canal skin to the
external canal.

Image showing canalplasty being performed

Prof Dr Balasubramanian Thiagarajan

Otoendoscopy

Introduction:

Advent of endoscopes have revolutionized

diagnosis and treatment of various disorders.
Otology is no exception to it. Otoendoscopes
are rigid endoscopes which have been used for
diagnostic purposes in the field of otology. This
procedure of Otoendoscopy was first described
by Mer et al.

Commonly used Otoendoscopes include:

1. 1.7 mm 0-degree Otoendoscope

2. 1.7 mm 30 degrees Otoendoscope Author pre-
fers to use the nasal endoscope itself for otolog- Image showing retracted ear drum
ical diagnostic purposes. The advantages being
the obvious optimization of instrument usage.
Advantages of using rigid endoscopes to per-
form otological examinations:
1. The entire ear drum can be clearly visualized
with minimal manipulation
2. The image produced is of excellent resolu-
tion hence photographing these images provide
excellent results.
3. Fluid levels in middle ear cavity due to otitis
media with effusion is clearly seen in Otoendos-
copy than in routine otoscopy.
4. Every nook and corner of external auditory
canal and middle ear cavity if tympanic mem-
brane perforation is present can easily be exam- Image showing glomus jugulare
ined with minimal manipulation of the endo-
scope.
5. It is easy to clear the debris from the external
auditory canal under visualization with an Oto-
endoscope.

Surgical techniques in Otolaryngology

64
Image showing otoendoscopic view of attic
perforation Image showing otoendoscopic view of otomyco-
sis

Image showing otoendoscopic view of acute

otitis media
Image showing otoendoscopic view of attic
cholesteatoma

Prof Dr Balasubramanian Thiagarajan

According to the author’s experience the follow- Endoscopic Myringoplasty
ing minor procedures can be easily performed
using Otoendoscopy:
Introduction:
1. Removal of epithelial debris from external
auditory canal Myringoplasty is a surgical procedure performed
2. Removal of cerumen to close tympanic membrane perforations.
3. Removal of otomycotic flakes The advent of operating microscope results of
4. Removal of maggots / foreign bodies myringoplasty started showing dramatic im-
5. Removal of aural polyp provements. This is attributed to the accuracy of
6. Suction clearance surgical technique. Major disadvantage of oper-
All these procedures can be commonly per- ating microscope is that it provides a magnified
formed as outpatient / day care procedures. image along a straight line. Success of myringo-
plasty should be assessed both subjectively and
objectively.

Subjective indicators include:

1. Improvement in hearing acuity

2. Absence of ear discharge
3. Absence of tinnitus
Objective indicators are:
1. Healed perforation as seen in Otoendoscopy
2. Improvement in hearing threshold demon-
strated by performing Puretone audiometry.

Image showing microscopic line of magnifica-

tion

Surgical techniques in Otolaryngology

66
 tone average)
4. Results of this procedure was compared to
that of published results of microscopic myrin-
goplasty Puretone audiometry was performed
for all these patients. All of them had 30 – 40 dB
conductive hearing loss
Success rate of endoscopic procedure was com-
pared with that of various studies performed
using microscopic approach. Internet survey
revealed a success rate of 71% - 80% success
rates in patients undergoing microscopic my-
ringoplasty. This highly variable success rate was
attributed to the different locations of perfo-
rations. Posterior perforations carried the best
success rates i.e. 90%.

Image showing endoscopic line of magnification Procedure:

Temporalis fascia graft is harvested under local

Advantages of endoscope: anesthesia conventionally and allowed to dry.
The external auditory canal is then anesthetized
1. It provides an excellent magnified image with using 2 % xylocaine mixed with 1 in 10,000
a good resolution adrenaline injection. About 1/2 cc is infiltrated
2. With minimal effort it can be used to visualize at 3 - o clock, 6 - o clock, 9 - o clock, and 12 - o
the nook and corners of middle ear cavity clock positions about 3mm from the annulus.
3. Magnification can be achieved by just getting The patient is premedicated with
the endoscope closer to the surgical field intramuscular injections of 1 ampule fortwin
4. Antero inferior recess of external auditory and 1 ampule phenergan.
canal can be visualized using an endoscope
5. Middle ear cavity can be visualized easily Step I: Freshening the margins of perforation
using an endoscope. Even difficult areas to visu- - In this step the margins of the perforation is
alize under microscopy like sinus tympani can freshened using a sickle knife of an angled pick.
easily be examined using an endoscope. This step is very important because it breaks the
Methodology: Inclusion criteria: adhesions formed between the squamous mar-
1. Patients in the age group of 20 -40 were in- gin of the ear drum (outer layer)
cluded in the study with that of the middle ear mucosa. These adhe-
2. All these patients had dry central perforation sions if left undisturbed will hinder the take up
of ear drum of the neo tympanic graft. This procedure will in
3. Patients with demonstrable degree of con- fact widen the already present perforation. There
ductive deafness was chosen (at least 30 dB pure is nothing to be alarmed about it.

Prof Dr Balasubramanian Thiagarajan

 viated tip portion of the handle can be clipped.
Step II: This step is otherwise known as eleva- The handle of the malleus is freshened and
tion of tympano meatal flap. Using a drum knife stripped of its mucosal covering.
a curvilinear incision is made about 3 mm lat-
eral to the annulus. This incision ideally extends Step V: Placement of graft (underlay technique).
between the 12 - o clock, 3 - o clock, and 6 - o Now a properly dried temporalis fascia graft of
clock positions in the left ear, and 12 - o clock, appropriate size is introduced through the ear
9 - o clock and 6 - o clock positions in the right canal. The graft is gently pushed under the tym-
ear. The skin is slowly elevated away from the pano meatal flap which has been elevated. The
bone of the external canal. Pressure should be graft is insinuated under the handle of malleus.
applied to the bone while elevation. The tympano meatal flap is repositioned in such
a way that it covers the free edge of the graft
This serves two purposes: which has been introduced. Bits of gelfoam are
placed around the edges of the raised flap. One
1. It prevents excessive bleeding gel foam bit is placed over the sealed perfora-
2. It prevents tearing of the flap. tion. This
This step ends when the skin flap is raised up to gelfoam has a specific role to play. Due to the
the level of the annulus. suction effect created it pulls the graft against
the edges of the perforation thus preventing
Step III: Elevation of the annulus and incising medialisation of the graft material.
the middle ear mucosa. In this step the annulus
is gradually lifted from its rim. As soon as the
annulus is elevated a sickle knife is used to incise
the middle ear mucosal attachment with the
tympano meatal flap. This is a
very important step because the inner layer of
the remnant ear drum is continuous with the
middle ear mucosa. As soon as the middle ear
mucosa is raised, the flap is pushed anteriorly till
the handle of the malleus becomes visible.

Step IV: Freeing the tympano meatal flap from

the handle of malleus. In this step the tympano
meatal flap is freed from the handle of malleus
by sharp dissection of the middle ear mucosa.
Sometimes the handle of the malleus may be
turned inwards hitching against the promontory.
In this scenario, an attempt is made to lateralise Image showing a subtotal perforation. Rim of
the handle of the malleus. If it is not possible to the perforation indicated by the dark line
lateralise the handle of the malleus, the small de-

Surgical techniques in Otolaryngology

68
 Image showing tympanomeatal flap being
Image showing the rim of the perforation being elevated. The incision is indicated by red line.
freshened with an angled pick Drum knife is seen in action.

Image showing the rim of the perforation being

removed using micro alligator forceps Image showing the flap being freed from its
superior attachment.

Prof Dr Balasubramanian Thiagarajan

Image showing tympanomeatal flap being Image showing the view of chorda tympani
elevated from the bony portion of the external nerve (Yellow color).
auditory canal. Bone is clearly visible after
elevation of the flap.

Image showing anterior pocket being created

for insertion and stabilization of the graft

Image showing middle ear being entered. Mid-

dle ear mucosa is indicated by yellow dots.

Surgical techniques in Otolaryngology

70
Image showing handle of the malleus being Image showing temporalis fascia being harvest-
skeletonized. ed

Image showing graft being inserted into the

canal Image showing graft being inserted under the
handle of malleus. This step adds stability to
the graft material

Prof Dr Balasubramanian Thiagarajan

 4. Its thickness is more or less similar to that of
tympanic membrane

There are two available methods of performing

myringoplasty:

Overlay technique

Under lay technique

Overlay technique:

This is a difficult technique to master. Here the

graft material is inserted under the squamous
(skin layer) of the ear drum. It is a difficult
task peeling only the skin layer away from the
tympanic membrane, placing the graft over the
Image showing graft in situ perforation and redraping the skin layer.

Classic myringoplasty Underlay technique:

Myringoplasty is a procedure used to seal a This is a simpler and commonly used technique.
perforated tympanic membrane using a graft Here the graft is placed under the tympano
material. meatal flap which has been elevated hence the
name under lay. The major advantage of this
Temporalis fascia is the commonly used graft procedure is that it is easy to perform with a
material because: good success rate.

1. It is an autograft with excellent chance of take

Indications of Myringoplasty
2. It is available close to the site of operation
making its harvest easier 1. Central perforation which has been dry at
least for a period of 6 weeks.
3. It has a low basal metabolic rate, brightening
2. As a follow up to mastoidectomy procedure to
its success rate
recreate the hearing mechanism

Surgical techniques in Otolaryngology

72
Prerequisites for myringoplasty
Step II:
1. Central perforation which has been dry for at
least 6 weeks This step is otherwise known as elevation of
tympano meatal flap. Using a drum knife a
2. Normal middle ear mucosa curvilinear incision is made about 3 mm later-
al to the annulus. This incision ideally extends
3. Intact ossicular chain between the 12 - o clock, 3 - o clock, and 6 - o
clock positions in the left ear, and 12 - o clock,
4. Good cochlear reserve 9 - o clock and 6 - o clock positions in the right
ear. The skin is slowly elevated away from the
Procedure: bone of the external canal. Pressure should be
applied to the bone while elevation. This serves
Firstly a temporalis fascia of adequate site must two purposes:
be harvested and allowed to dry. The surgery is
performed under local anesthesia. Temporalis 1. It prevents excessive bleeding
fascia graft is harvested under local anesthesia
conventionally and allowed to dry. The external 2. It prevents tearing of the flap
auditory canal is then anesthetised using 2 %
xylocaine mixed with 1 in 10,000 adrenaline in- This step ends when the skin flap is raised up to
jection. About 1/2 cc is infiltrated at 3 - o clock, the level of the annulus.
6 - o clock, 9 - o clock, and 12 - o clock positions
about 3mm from the annulus. The patient is Step III:
premedicated with intramuscular injections of 1
ampule fortwin and 1 ampule phenergan. Elevation of the annulus and incising the middle
ear mucosa. In this step the annulus is gradu-
Step I: ally lifted from its rim. As soon as the annulus
is elevated a sickle knife is used to incise the
Freshening the margins of perforation - In this middle ear mucosal attachment with the tym-
step the margins of the perforation is freshened pano meatal flap. This is a very important step
using a sickle knife of an angled pick. This step is because the inner layer of the remnant ear drum
very important because it breaks the adhesions is continuous with the middle ear mucosa. As
formed between the squamous margin of the ear soon as the middle ear mucosa is raised, the flap
drum (outer layer) with that of the middle ear is pushed anteriorly till the handle of the malle-
mucosa. These adhesions if left undisturbed will us becomes visible.
hinder the take up of the neo tympanic graft.
This procedure will in fact widen the already Step IV:
present perforation. There is nothing to be
alarmed about it. Freeing the tympano meatal flap from the han-

Prof Dr Balasubramanian Thiagarajan

dle of malleus. In this step the tympano meatal
flap is freed from the handle of malleus by sharp Tympanoplasty
dissection of the middle ear mucosa. Sometimes
the handle of the malleus may be turned inwards The fundamental principles of Tympanoplasty
hitching against the promontory. In this scenar- were introduced by Zollner and Wullstein. These
io, an attempt is made to lateralise the handle principles were directed towards restoration of
of the malleus. If it is not possible to lateralise middle ear function as well as ensured trouble
the handle of the malleus, the small deviated tip free and stabilized ear.
portion of the handle can be clipped. The handle
of the malleus is freshened and stripped of its Wullstein and Zollner classified Tympanoplasty
mucosal covering. according to the type of ossicular reconstruction
needed. Five types of Tympanoplasty have been
Step V: classified.
Placement of graft (underlay technique). Now a Type I Tympanoplasty:
properly dried temporalis fascia graft of appro-
priate size is introduced through the ear canal. This is indicated in patients with presence of all
The graft is gently pushed under the tympano the middle ear ossicles with normal mobility.
meatal flap which has been elevated. The graft Ossicular chain reconstruction is not needed in
is insinuated under the handle of malleus. The these patients. Efforts are made to close the per-
tympano meatal flap is repositioned in such forated ear drum using temporalis fascia graft
a way that it covers the free edge of the graft (Hong Kong flap). This procedure is also known
which has been introduced. Bits of gelfoam is as myringoplasty.
placed around the edges of the raised flap. One
gel foam bit is placed over the sealed perfora- Advantages of using temporalis fascia as graft
tion. This gelfoam has a specific role to play. Due material
to the suction effect created it pulls the graft
against the edges of the perforation thus pre- 1. It is an autograft with excellent chance of take
venting medialisation of the graft material. 2. It is available close to the site of operation
making its harvest easier
3. It has a low basal metabolic rate, brightening
its success rate
4. Its thickness is more or less similar to that of
tympanic membrane

Surgical techniques in Otolaryngology

74
 Indications of Myringoplasty:

1. Central perforation which has been dry at

least for a period of 6 weeks.
2. As a follow up to mastoidectomy procedure to
recreate the hearing mechanism

Prerequisites for myringoplasty:

1. Central perforation which has been dry for at

least 6 weeks
2. Presence of normal middle ear mucosa
3. Intact ossicular chain
4. Good cochlear reserve

Procedure: Firstly a temporalis fascia of ade-

Image showing Type I tympanoplasty quate site must be harvested and allowed to dry.
The surgery is performed under local anesthesia.
Temporalis fascia graft is harvested under local
There are two available techniques for perform- anesthesia conventionally and allowed to dry.
ing myringoplasty / type I Tympanoplasty. The external auditory canal is
1. Overlay technique then anesthetized using 2 % xylocaine mixed
2. Under lay technique with 1 in 10,000 adrenaline injection.

Overlay technique: This is a difficult technique About 1/2 cc is infiltrated at 3 - o clock, 6 - o

to master. Here the graft material is inserted un- clock, 9 - o clock, and 12 - o clock positions
der the squamous (skin layer) of the ear drum. about 3mm from the annulus. The patient is
It is a difficult task peeling only the skin layer premedicated with intramuscular injections of 1
away from the tympanic membrane, placing the ampoule fortwin and 1 ampoule phenergan.
graft over the perforation and redraping the skin
layer. Step I: Freshening the margins of perforation
- In this step the margins of the perforation is
Underlay technique: This is a simpler and com- freshened using a sickle knife of an angled pick.
monly used technique. Here the graft is placed This step is very important because it breaks the
under the tympano meatal flap which has been adhesions formed between the squamous mar-
elevated hence the name underlay. The major gin of the ear drum (outer layer)
advantage of this procedure is that it is easy to with that of the middle ear mucosa. These adhe-
perform with a good success rate. sions if left undisturbed will hinder the take up
of the neo tympanic graft. This procedure will in

Prof Dr Balasubramanian Thiagarajan

fact widen the already present perforation. There In this scenario, an attempt is made to lateralize
is nothing to be alarmed about it. the handle of the malleus. If it is not possible to
lateralize the handle of the malleus, the small
Step II: This step is otherwise known as eleva- deviated
tion of tympano meatal flap. Using a drum knife tip portion of the handle can be clipped. The
a curvilinear incision is made about 3 mm lat- handle of the malleus is freshened and stripped
eral to the annulus. This incision ideally extends of its mucosal covering.
between the 12 - o clock, 3 - o clock, and 6 - o
clock positions in the left ear, and 12 - o clock, Step V: Placement of graft (underlay technique).
9 - o clock and 6 - o clock positions in the right Now a properly dried temporalis fascia graft of
ear. The skin is slowly elevated away from the appropriate size is introduced through the ear
bone of the external canal. Pressure should be canal. The graft is gently pushed under the tym-
applied to pano meatal flap which has been elevated. The
the bone while elevation. This serves two pur- graft is insinuated under the handle of malleus.
poses: The tympano meatal flap is repositioned in such
a way that it covers the free edge of the graft
1. It prevents excessive bleeding which has been introduced. Bits of gelfoam are
2. It prevents tearing of the flap. placed around the edges of the raised flap. One
gel foam bit is placed over the sealed perfora-
This step ends when the skin flap is raised up to tion. This gelfoam has a specific role to play. Due
the level of the annulus. to the suction effect created it pulls the graft
against the edges of the perforation thus pre-
Step III: Elevation of the annulus and incising venting medialisation of the graft material.
the middle ear mucosa. In this step the annulus
is gradually lifted from its rim. As soon as the Type II Tympanoplasty: In this procedure the
annulus is elevated a sickle knife is used to incise tympanic membrane is grafted to the intact
the middle ear mucosal attachment with the incus and stapes. This procedure is very rarely
tympano meatal flap. This is used, since it is very rare for erosion of the han-
a very important step because the inner layer of dle of malleus to be present alone without the
the remnant ear drum is continuous with the involvement of other ossicles. The
middle ear mucosa. As soon as the middle ear neotympanum created is draped over the exist-
mucosa is raised, the flap is pushed anteriorly till ing incus and stapes. There is a certain amount
the handle of the malleus becomes visible. of obliteration of middle ear space.

Step IV: Freeing the tympano meatal flap from Since the ossicular chain lever ratio is not nor-
the handle of malleus. In this step the tympano mally maintained in these patients, they
meatal flap is freed from the handle of malleus tend to have at least 30 dB hearing loss even
by sharp dissection of the middle ear mucosa. after a successful surgery.
Sometimes the handle of the malleus may be
turned inwards hitching against the promontory.

Surgical techniques in Otolaryngology

76
 grafted ear drum virtually drapes the promon-
tory.

Even after successful surgery these patients

would still have about 40 – 50 dB hearing loss.

Image showing Type II tympanoplasty

Type III Tympanoplasty: This technique is used

only when a mobile suprastructure of stapes
alone is present. In this surgical procedure the Image showing Type III tympanoplasty
tympanic membrane graft is draped over the
mobile suprastructure of stapes. This is also
known as Columella effect. This type of middle
ear is commonly seen in birds.

The middle ear space is really non existent. Even

after successful surgery these patients still man-
ifest with 30 – 40 dB hearing loss. This surgical
procedure is useful in patients without malleus
and incus. Incus has the most precarious blood
supply among the three ossicles.

Type IV Tympanoplasty: This surgical procedure

is performed in patients only with mobile foot Image showing Type IV tympanoplasty
plate of stapes. The grafted ear drum is draped
over the mobile foot plate. In these patients
there is virtually no middle ear space at all. The

Prof Dr Balasubramanian Thiagarajan

In this surgical procedure the round window is Austin in 1971 classified the anatomical defects
protected from the incoming sound waves. This found in the ossicular chain due to chronic sup-
helps in preserving the round window baffle purative otitis media. Isolated losses of handle
effect. of malleus and stapes suprastructure were not
included in this classification due to their rarity.
Type V Tympanoplasty: In this surgical proce-
dure a third window is created over the lateral Type I – Normal = M+I+S
semicircular canal. (Fenestra over lateral canal). Type II – M+S – Absent incus – Good prognosis
This surgical procedure is outdated these days. Type III – Malleus + Foot plate of stapes – poor
prognosis.
Belluci’s prognostic classification: Belluci used
the status of middle ear cavity in determining The forerunner of partial and total ossicular
the prognostic features of Tympanoplasty. He replacement prosthesis was Dr. Austin’s polyeth-
grouped those under 4 heads. ylene malleus to foot plate strut. He designed the
“sunflower Columella”
Group I: Patients with a dry ear for a period of at designed out of Teflon. Teflon and polyethylene
least 6 months fall in this category. has the advantage of excellent air bone closure.
Group II: Patients with occasionally draining ear
was included in this group. The following are the various categories of
Group III: Patients with persistent ear drainage bio-materials used in ossiculoplasty:
associated with mastoiditis were included
in this group. 1. Polyethylene tubing
Group IV: Patients with persistent ear discharge 2. Polytetrafluoroethylene (Teflon)
associated with palatal malformations (cleft pal- 3. Gelatin foam (Gelfoam)
ate) were included in this group. 4. Silastic (Dimethyl silicone polymer)
5. Platinum – This material is very ductile, non
Ossicular grafts have revolutionized Tympano- magnetic and bio-compatible.
plasty procedure these days. These grafts help in 6. Titanium alloy
the preservation of middle ear space, as well as 7. Polycel and plastipore
produces excellent improvement in hearing. 8. Capcel – Hydroxyapatite
9. Otocel – Clear bioactive bioglass (ceramic
Implants used for ossiculoplasty should satisfy material)
four basic requirements:

1. They should be bio-compatible and should

not extrude / cause severe tissue reaction
2. They should improve / maintain hearing
3. They should be technically easy to use
4. They should maintain results over time

Surgical techniques in Otolaryngology

78
 Stapes to malleus reconstruction:
Selection of prosthesis:
When malleus is present, it can be used to help
Factors to be considered while selecting an opti- to stabilize thee prosthesis and reduce the possi-
mal prosthetic design are: bility of extrusion. The malleus is never directly
1. Status of ear drum aligned to the underlying stapes (M-S offset). A
2. Status of residual ossicles variety of implants have been designed to take
3. Severity of Eustachian tube dysfunction advantage of the stabilizing effect of malleus.
4. Stability of prosthesis
5. Ease of placement Incus interposition: Guilford transposed the
6. Sound conductivity residual incus autograft on to its side so that it
lies on the stapes capitulum and beneath the
manubrium. Hearing results could be excellent

Prof Dr Balasubramanian Thiagarajan

if the middle ear anatomy is favorable. The incus
remnants could be too short
or long. Too long a incus prosthesis could lead
to ankylosis. Revision surgery is difficult in such
patients owing to the fixation of the prosthesis to
the stapes and fallopian canal.

Zollner’s sculpted incus: Zollner popularized the

sculpturing of Autologous incus. This helps in
obtaining a better fit. It also reduces the inci-
dence of subsequent ankylosis.

Weher’s refined this technique to include ho-

mograft ossicles. This technique could be time
consuming. Remnant Autologous incus could
harbor cholesteatoma. Image showing Grote prosthesis

Grote Hydroxyapatite assembly: Grote devel-

oped the first commercial Hydroxyapatite pros-
thesis. Its configuration attempted to accom-
modate the M-S offset. This prosthesis should
be placed lateral to the malleus necessitating
dissection of the ear drum away from the malle-
us. There is also the associated risk of iatrogenic
perforation of the ear drum.

Wehr’s Hydroxyapatite prosthesis: Wehr’s ad-

vocated sculpted homograft for incus interpo-
sition. He also developed Hydroxyapatite incus
prosthesis in order to reduce the preparation
time inside the operation theatre during ossic-
uloplasty procedures. This prosthesis had an
anterior extension which was created to cradle Image showing the Wehr’s prosthesis. The ante-
the malleus. Biocompatibility of this material rior cradle supports the malleus.
was really superior.

Surgical techniques in Otolaryngology

80
 Image showing Weher’s prosthesis
Image showing stapes replacement prosthesis

There are two types of Weher’s prosthesis: Kartush Hydroxyapatite struts: These struts were
designed to function as either a TORP or PORP.
1. Incus replacement prosthesis Hydroxyapatite was used. This prosthesis has a
2. Incus – Stapes replacement prosthesis self locking mechanism. It has very low displace-
ment and extrusion rates.

Image showing incus replacement prosthesis

Image showing Kartush prosthesis

Prof Dr Balasubramanian Thiagarajan

Incus interposition ossiculoplasty: Incus due to frequency function at the expense of low fre-
its precarious blood supply commonly under- quencies.
goes necrosis, especially its long process. Homo- 5. Prosthesis that connects malleus to stapes
graft incus was shaped and placed between the appears to have no acoustic advantage over pros-
malleus and stapes head. A notch was created thesis that connects the ear drum to the stapes.
in the short process of the incus that fit under 6. If the ear drum is conical, prosthesis with
the malleus handle. This is done to stabilize the the head angulated at about 30° appears to be
ossicles. If the stapes suprastructure was intact beneficial because the angulation increases the
in the patient, the long process of incus was am- surface area in contact with
putated. A small cup was made in the amputated the ear drum.
long process of incus. The head of the stapes fits
into this cup. The notch prevented the prosthesis These prostheses may be used to reconstruct
from being displaced anteriorly / posteriorly. the ossicular chain during Tympanoplasty, in
The spring in the patient’s malleus would keep patients in whom erosion and discontinuity
the prosthesis from being displaced inferiorly. of ossicular chain has occurred. Long process
Superiorly its position is maintained by the con- of incus gets frequently eroded because of its
traction of tensor tympani tendon. precarious blood supply. In these cases the
lenticular process of incus is still attached to
When the stapes superstructure is absent, the the head of stapes. The incudo stapedial joint in
long process of incus could be placed over the these patients should be separated and the long
foot plate of stapes. process of incus removed. This is done because
squamous debris could still be attached to the
Pitfalls: With AID’s being common these days, incus fragment. It is also preferable to remove
incus homograft has given way to artificially the body of the incus, because it could also have
designed prosthesis. Hydroxyapatite was com- squamous ingrowth. It can also have scar tissue
monly used to design these prosthetic incus blocking the antrum.
replacements.
Surgical procedure:
Factors that should be taken into consideration
before designing the optimal prosthesis: The prosthesis is laid on its side on the promon-
tory. The cup of the prosthesis is near the stapes
1. Proper tension is very important. A prosthe- and its notched portion close to the tip of the
sis that makes tension adjustment easy for the handle of malleus. With the help of right-angle
surgeon should be advantageous. pick held in the surgeon’s left hand, the malleus
2. Prosthesis with masses less than 40mg is best is elevated, and with a gently curved pick in the
for overall acoustic performance. surgeon’s right hand, the prosthesis is brought
3. For improved high frequency performance, up under the manubrium of the malleus. As it is
rigid low mass prosthesis (less than 10g) is the brought to an upright position, the cup engages
best choice. the head of stapes.
4. Longer prosthesis produces excellent high

Surgical techniques in Otolaryngology

82
Image showing the prosthesis laid on its side on
the promontory

Image showing prosthesis in final position

Ossicular reconstruction with prosthesis of

Hydroxyapatite should not be attempted in cases
of acute trauma / traumatic perforation of ear
drum. It should be performed only after the
drum has healed and stabilized.

Complications:

Owing to the biocompatibility of this prosthesis,

the incidence of complications is rare.
Image showing the prosthesis being positioned 1. Extrusion of the prosthesis.
2. Too short / Too long prosthesis could lead to
increased extrusion rates
3. Failure to improve hearing
The success or failure of ossiculoplasty proce-

Prof Dr Balasubramanian Thiagarajan

dure could be assessed by calculating the Middle
Ear Risk (MER) Index. In this index a value is
assigned for each risk factor, and these values are
added to determine the MER index.

The success or failure of ossiculoplasty proce-

dure could be assessed by calculating the Middle
Ear Risk (MER) Index. In this index a value is
assigned for each risk factor, and these values are
added to determine the MER index.

Ossiculoplasty using presculptured banked

cartilage:

Homologous cartilage can be sculptured prior to

surgery into TORP / PORP configuration. They
can easily be stored by a tissue bank for use at
a later date. It is configured in a self stabilizing
manner with a disk shaped upper surface.

Donors should be screened serologically for

Hepatitis and HIV antigens. Costal cartilage
is ideal for this purpose. Graft material is har-
vested from the costochondral cartilages. These
cartilages are fashioned into TORP type im-
plants. The classic TORP configuration is about
8 mm long. It has a disk like head of about 4 mm
diameter. The diameter of the shaft should be 2
mm in diameter.

According to MER:

0 – Best prognosis
2 – Mild risk

Surgical techniques in Otolaryngology

84
5 – Moderate risk tion in the absence of stapes suprastructure is
7 – Severe risk technically more demanding. Cartilaginous
12 – Worst prognosis homografts are effective if the patient has a wide
oval window niche. Measurements are taken as
described for PORP configuration.

The length of the shaft should be trimmed and

contoured as per requirements. If there is a per-
foration in the tympanic membrane that corre-
sponds with the location of
the disk shaped head of the reconstruction pros-
thesis, the head of the prosthesis itself can be
used as a graft for the perforation. The surface of
the TORP readily epithelializes.

Image showing PORP configuration to be used Advantages of presculptured homograft cartilage

when malleus is absent as prosthesis:

1. The incidence of graft extrusion is rare

2. Contact of the implant with adjacent bony
walls of middle ear can be consistent with
excellent hearing results, because the cartilage
remains flexible.
3. Hearing improvement is excellent
4. Operating technique is less demanding when
presculptured cartilage homograft is
used.

Ossiculoplasty with composite prosthesis:

PORP’s and TORP’s designed out of composite
Image showing PORP configuration to be used materials was first popularized by Sheehy and
when malleus is present Shea. Major advantage of using
synthetic graft is there is no fear of transmission
The disk like top of the implant can be placed in of diseases like HIV and Hepatitis.
contact with the posterior bony annulus for add-
ed stabilization. It is better to thin the cartilage Composite prosthesis has two distinct por-
in the area of contact with the annulus, thereby tions: a Hydroxyapatite head and a plastipore or
minimizing the potential for dense adhesions. fluoroplastic shaft. The Hydroxyapatite head is a
universal design, and no modification or intra-
TORP configuration: Ossicular reconstruc- operative reshaping is required. The plastipore

Prof Dr Balasubramanian Thiagarajan

shaft is manufactured in such a way
that it can be precisely trimmed to within a 0.5
mm variance on the basis of intraoperative mea-
surements.

The type of Hydroxyapatite head that should

be used in the prosthesis depends upon wheth-
er malleus is present or absent. In cases where
malleus is present, the head of the prosthesis
used should be in the form of a delicate hook. It
is designed in such a way that the hook is po-
sitioned under the handle of the malleus. The
Hydroxyapatite head to be when the malleus is
absent has a flat, egg shaped design, with gently
rounded edges.
This design facilitates easy insertion under the
ear drum without the need for cartilage inter-
position. This prosthesis is best used when the Image showing the types of composite prosthesis
middle ear is healthy and free of in use
disease.

The plastipore shaft is of two types:

Contraindications for composite prosthesis:
1. Type I: The shaft has a hollow sleeve to ac-
commodate the head of stapes
2. Type II: The shaft is more slender, wire rein- 1. Should not be used in patients with severe
forced. This design helps the shaft to rest directly Eustachian tube function.
on the foot plate of stapes / oval window. 2. Should not be used in patients with an obliter-
ated middle ear space.
There are 4 types of composite prosthesis de- 3. Middle ear mucosa should be healthy and free
signed to solve the four basic problems encoun- of any disease.
tered during ossicular reconstruction. These
situations include:

• Malleus present, stapes present

• Malleus present, stapes absent
• Malleus absent, stapes present
• Malleus absent, stapes absent

Surgical techniques in Otolaryngology

86
 Spandrel: This is a type of TORP. It has a wide
head which can be slid under the ear drum and
a narrow shaft. The length of the shaft can be re-
duced by cutting it. The shaft rests over the foot
plate of stapes.

Parts of spandrel: It has a perforated shoe to

allow protrusion of the wire core. It has a thin
flange on the prosthesis head to avoid possible
damage induced by a sharp edge of the Polycel
Image showing standard TORP configuration disk.

Cartilage harvested from rib is cut into 8 mm

sections. They are then placed over sterile hard
surface. Using a 4mm disposable dermal punch
cylinders of cartilage are created each with 4
mm diameter and 8 mm long. From these cylin-
drical grafts, appropriately shaped TORP’s can
be prepared. Cartilage material can be placed in
sterile saline and put in glass specimen sterile
bottles and sealed with a plastic seal.

PORP configuration: When stapes is present and

mobile, a measurement is taken from the lateral
most part of the capitulum of the stapes to the
ear drum. 1 mm should be
added to this value, and the TORP blank car-
tilage is trimmed to this measurement. A de-
pression is made in the end of the shaft of the Image showing a Spandrel.
trimmed blank to accommodate the head of the
stapes. The depth of this indentation could be Before assembling the prosthesis, air is removed
about 0.5 – 1 mm. The 4 mm disk of the top of from the Polycel casing by connecting the
the implant should be in complete contact with prosthesis and its shoe to a syringe containing
the ear drum. If an intact malleus handle is pres- Ringer’s solution and antibiotic.
ent, the anterior most portion of the head of the This prosthesis ensures better closure of air bone
implant can be trimmed to fit the handle. If the gap.
malleus handle is absent, a more flat configura-
tion can be used.

Prof Dr Balasubramanian Thiagarajan

 patient doesn’t have middle ear effusion. Symp-
toms are usually fluctuating (disequilibrium,
Grommet Insertion tinnitus, vertigo, auto phony and severe retrac-
tion pocket).
Introduction:
6. Otitis barotrauma in order to prevent recur-
Myringotomy with grommet insertion was rent episodes.
introduced by Poltizer of Vienna in 1868. He
used this procedure to manage “Otitis media ca- 7. To administer intratympanic medications
tarrhalis”. Soon it became the common surgical
procedure performed in children. Problems with Grommet insertion:

Indications: This procedure is not without its attendant prob-

lems.
Bluestone and Klein (2004) came out with re-
vised indications for grommet insertion which Common problems include:
took into consideration the prevailing antibiotic
spectrum. 1. Segmental atrophy of tympanic membrane
Tympanosclerosis
1. Chronic otitis media with effusion not re-
sponding to antibiotic medication and has 2. Persistent perforation syndrome (rare) Before
persisted for more than 3 months when bilateral treating patients with otitis media with effusion
or 6 months when unilateral. the following factors should be borne in mind.
Pneumatic otoscopy should be used to differen-
2. Recurrent acute otitis media especially when tiate otitis media with effusion from acute otitis
antibiotic prophylaxis fails. The minimum epi- media. Duration of symptoms should be careful-
sode frequency should be 3/4 during previous 6 ly documented. Children with risk for learning /
months / 4 or more attacks during previous year. speech problems should be carefully identified.
Hearing should be evaluated in all children who
3. Recurrent episodes of otitis media with effu- have persistent effusion for more than 3 months.
sion in which duration of each episode does not Grommet insertion can be performed under
meet the criteria given for chronic otitis media local anesthesia. Incision is made in the antero
but the cumulative duration is considered to be inferior quadrant of ear drum. The incision is
excessive (6 episodes in the previous year) given along the direction of radial fibers of the
middle layer of ear drum. This causes minimal
4. Suppurative complication is present / sus- damage to the radial fibers. It also enables these
pected. It can be identified if myringotomy is fibers to hug the grommet in position.
performed.

5. Eustachean tube dysfunction even if the

Surgical techniques in Otolaryngology

88
Image showing the site of incision in the ear Image showing glue flowing out after the inci-
drum sion

Image showing grommet being introduced

Image showing incision being given using sickle
knife

Prof Dr Balasubramanian Thiagarajan

 He also suggested that this condition could be
relieved by incising the eardrum. The first myr-
ingotomy was reported in 1649 by Jean Riolan
a French anatomist who described an improve-
ment in hearing following intentional laceration
of the tympanic membrane with a ear spoon.
He also hypothesized that artificial perforations
of the ear drum could be a cure for congenital
deafness.

Image showing grommet being pushed into the During 17th and 18th centuries, many famous
perforation surgeons attempted to explain the relationship
between the ear drum and hearing. William
Cheselden completed animal studies by per-
forming myringotomy. He wanted to conduct
human trials which was prevented. In 1748,
Julius Busson became the first person to rec-
ommend perforating the ear drum if pus was
present medial to it. Peter Degraers performed
myringotomy in Edinburgh. Sir Astley Paston
Cooper, a surgeon to Guy’s hospital can be con-
sidered the first to outline clear indications for
myringotomy.

Home was the first to describe the radial fibers

Image showing grommet in situ of the ear drum. He used a trocar concealed
within a cannula to create a perforation in the
History: ear drum. This trocar and cannula was designed
by Ashey Cooper. The procedure performed
The term Grommet is derived from the French was really blind, and his only indication for this
word gourmer (“to curb”). procedure was deafness due to eustachean tube
obstruction. He also insisted that bone conduc-
The first era of myringotomy tion should be intact in these patients.

Otitis media with effusion is an age old problem In 1804 Christian Michalis a professor of anat-
affecting young children and infants. The term omy from marburg performed tympanic mem-
“glue ear” was first coined in the year 1960. This brane perforations in 63 patients. Cooper’s strict
condition was first described by Hippocrates indication of having good bone conduction
and Aristotle. In 400 BC, Hippocrates described before performing myringotomy was ignored by
how the middle ear become filled with mucous. subsequent surgeons at their own peril.

Surgical techniques in Otolaryngology

90
 tempt to liquefy the middle ear fluid facilitating
removal. Adam Politzer was actually credited
with the first use of suction to remove fluid. It
was noted by him that one of the drawbacks of
myringotomy was that the site of incision healed
spontaneously and very quickly.

Earliest attempts to prevent rapid healing was

described by Antoine Saissy in 1829. He used an
oiled catgut string to keep the perforation open.
In Italy during the 18th century Monteggio
attempted to maintain the opening with cautery.
About the same time the German Ophthalmol-
ogist Himly devised a larger trocar for the same
reason.
Image showing Ashey Cooper trocar and can-
nula The focus of this phase is the search for success-
ful method of maintaining the ear drum perfo-
Second Era ration open. Essentially the focus was divided
into two schools of approach. The first one was
In the mid-19th century few surgeons were still led by Philippeaux and Gruber who removed
performing myringotomy. Toynbee of St Mary’s sections of the ear drum, progressing from larg-
hospital happens to be one among them and his er myringotomies to wedge-shaped excisions.
assistant James Hilton was the other. Toyenbee Though this approach left a reasonably large
was the first to document insertion of a tube in opening in the ear drum for a reasonable period
the myringotomy performed to keep the middle of time, this was not a dependable one always.
ear ventilation going for long period of time. In some cases the annulus portion of the ear
In Dublin Sir William Wilde was using a sickle drum was also removed.
knife to incise the antero inferior quadrant of
the ear drum and followed it up with silver ni- The second school of surgeons headed by
trate cautery of the edges to keep the perforation Politzer searched for a foreign body that would
open. sit within the perforation and keep it open.
They also found that Saissy’s catgut insertion /
Myringotomy was reintroduced into otologi- insertion of a lead wire / whale bone insertion
cal practice in the latter half of 19th century by did not work reliably to keep the perforation
Schwarte and Politzer. They advised this proce- open. In 1845 it was Martel Frank who de-
dure only for fluid collections in the middle ear scribed the use of a small gold tube to keep the
cavity. Schwartze and his contemporaries tried ear drum perforation open by inserting it into
instilling medications via eustachean tube, as the middle ear cavity via the perforation. This
well as via the external auditory canal in an at- method had a reasonable degree of success de-

Prof Dr Balasubramanian Thiagarajan

spite its temporary nature. Politzer described a from occurring. The prevalence of secretory
rubber grommet in 1868, which had three flang- otitis media increased rather dramatically in
es and 2 grooves to allow it to sit across the ear this era. In 1954, American surgeon Beverley
drum as well as a silk thread to prevent it falling Armstrong used insertion of ventilation tube as
into the middle ear cavity. This resembled the a new treatment modality in managing patients
currently available grommets. This grommet with secretory otitis media. He first introduced
was adopted by Dalby, but it remained in place the concept of modern grommet and used plas-
only for a few months before extruding. He also tic grommets. He also recommended removal
observed that sometimes it would be necessary of the grommet after 4 weeks in order to allow
to insert a fresh grommet to keep the perfora- perforation to close. It was found to remain
tion open. Voltolini developed a gold ring in in situ for much longer if left alone. He in his
1874, and later modified it with aluminum. He writings related the success of grommet inser-
incised the anterior and posterior to the malleus tion to a beveled end which acts to secure the
and placed the ring around the handle. This also tube within the opening. In 1959, he designed
was not useful. the first flanged tube molded of polypropylene.
In 1965 he designed a Teflon tube with a slop-
Added to these problems surgeons encountered ing flange which was easier to insert through a
other complications like post operative infec- smaller incision. He patented the “Armstrong
tion, and foreign body reaction. Since this hap- V” in 1981. This tube was designed for easy,
pened to be the preanitbiotic era surgeons really precise insertion and to accommodate the anat-
found it hard to manage infections following the omy. The flange was supposed to have an entry
procedure. They then started to focus on ade- tab for easy insertion via the myringotomy and
noid and tonsil removal. Adenotonsillectomy comes complete with a stainless steel insertion
surgery became a panacea of all illness during instrument that fits onto a tab on the lateral end
the later part of the second era. of the tube. Armstrong the original designer to
the tube advised myringotomy to be made in
Third era the anterosuperior quadrant of the drum imme-
diately adjacent to the fibrous annulus. He also
The third era of myringotomy and grommet in- believed that incision at any other site will lead
sertion followed the second world war. The first to a premature extrusion of the tube, on the oth-
set of antibiotics had arrived and post operative er hand the right tube in the right place would
infections became treatable. Introduction of remain in situ for two years and above.
antibiotics ensured that acute otitis media could
be treated and the incidence of acute mastoid- Myringotomy became a standard treatment for
itis decreased dramatically. This reduced the glue ear with or without adenoidectomy. 91%
number of cortical mastoidectomies and otolo- of American otolaryngologists found ventilating
gists had time and energy to manage less serious tubes to be more effective than antibiotics in
conditions. During the first half of the 20th preventing acute otitis media. Radio-frequency
century, the otologists were treating the sequel assisted myringotomy is known to delay closure.
of serous otitis rather than preventing the sequel Closure can still be delayed if mitomycin C is

Surgical techniques in Otolaryngology

92
applied to the perforation edges. obstructing the vision then it must also be re-
moved.
Applied anatomy
An incision is given along the the anteroinferior
The tympanic membrane is an oval, thin, quadrant of the ear drum along the direction of
semi-transparent membrane separating the the radial fibers of the ear drum. The incision
external and middle ear cavity. The tympanic should be approximately 3-5 mm in length.
membrane is divided into 2 parts: Grommet is inserted into the opening and the
Pars flaccida and pars tensa. The manubrium radial fibers hold the grommet in position keep-
of the malleus is attached to the medial tym- ing the perforation open.
panic membrane; where the manubrium draws
the tympanic membrane medially, a concavity
is formed. The apex of the concavity is called
the umbo. The area of tympanic membrane
superior to umbo is termed as pars flaccida; the
remainder of the ear drum is known as the pars
tensa.

Procedure

Myringotomy is usually performed as an outpa-

tient procedure in adults and local anesthesia is
used. In children and infants general anesthesia
is preferred.

Equipment needed:

Pneumatic otoscope

Speculum

Myringotomy knife

Grommets

The head of the patient is tilted slightly towards

the opposite ear. Thee operative microscope
is brought into the field and focused on the
external auditory canal. If cerumen is found

Prof Dr Balasubramanian Thiagarajan

 4. Patient with tinnitus and vertigo
Stapedectomy
5. Presence of active otosclerotic foci (otospon-
This surgical procedure is performed to treat giosis) as evidenced by a positive flemmingo
deafness due to otosclerosis. Otosclerosis is sign. Since a patient with otosclerosis is also an
caused by fixation of the foot plate of stapes ideal candidate for hearing aid and surgery, the
which prevents efficient sound transmission to patient must be properly counseled regarding
the oval window. The deafness caused is conduc- the advantages and disadvantages of both.
tive in nature. The surgical procedure is per-
formed under local anesthesia. The position of the patient is made so that the
surgeon can see directly down the ear canal
Advantages of performing this surgery under from a sitting position.
local anesthesia are:
Anesthesia:
1. Improvement in hearing can be ascertained
on the table. Xylocaine with adrenaline mixed in concentra-
tion of 1:1000 is used to infiltrate the external
2. Bleeding is minimal under local anesthesia. auditory canal. 0.25 ml of the solution is infil-
trated using a 27 gauge needle. Infiltration is
Indications for stapedectomy: given as illustrated in the diagram.
Exposure:
1. Conductive deafness due to fixation of stapes.
A large speculum is used to straighten the
2. Air bone gap of at least 40 dB. external auditory canal. A curved or triangu-
lar incision is made in the external canal skin
3. Presence of Carhart’s notch in the audiogram beginning at 2mm away from the annulus. The
of a patient with conductive deafness. incision extends from 11 o clock position to 6
o clock position as viewed in the right ear. The
4. Good cochlear reserve as assessed by the pres- tympano meatal flap is elevated up to the an-
ence of good speech discrimination. nulus. Using a sharp pick the annulus is slowly
lifted from its groove, the middle ear mucosa is
Contraindications for stapedectomy: excised and the middle ear proper is entered.

1. Poor general condition of the patient. The chorda tympani nerve will come into view
immediately on entering the middle ear cavity.
2. Only hearing ear.
In most patients the posterior superior bony
3. Poor cochlear reserve as shown by poor overhang must be curetted using a curette (de-
speech discrimination scores signed by House). The long process comes into
view. Curetting is continued till the base of the

Surgical techniques in Otolaryngology

94
pyramidal process is visualised. Oval window 8. Perilymph fistula
is visualised. At this point round window reflex
is tested by moving the handle of malleus and 9. Labyrinthitis
looking for movement of round window mem-
brane. In otosclerosis this reflex is absent.

Using a hand burr a small fenestra about 0.6mm

in diameter is made over the foot plate. The
stability of the incus is left intact because the sta-
pedial tendon is not cut at this point. From now
on the steps may vary according to the surgeon’s
viewpoint. Some surgeons would like to insert
the piston at this stage without disturbing the
stability of the incus. The distance between the
long process of incus and the foot plate is mea-
sured using a measuring rod. Appropriate size
Teflon piston is introduced and hung over the
long process of the incus and is crimped after
ascertaining whether its lower end is inside the
fenestra. The stapedial tendon is cut at this point Image showing the site of incision in stapedec-
and the supra structure of the stapes is disartic- tomy
ulated and removed. The Tympanomeatal flap is
repositioned.

Complications of stapedectomy:

1. Facial palsy

2. Vertigo in the immediate post op period

3. Vomiting

4. Peri lymph gush

5. Floating foot plate Image showing tympanomeatal flap being

elevated
6. Tympanic membrane tear

7. Dead labyrinth

Prof Dr Balasubramanian Thiagarajan

 Image showing bony overhang being curetted

Image showing middle ear cavity being en-

tered. Middle ear mucosa is indicated by the
yellow arrow

Image showing chorda tympani nerve pushed Image showing stapedial tendon being cut
anteriorly

Surgical techniques in Otolaryngology

96
Image showing suprastructure of stapes being
sectioned Image showing piston being introduced

Image showing Piston introduction complete.

Image showing foot plate being fenestrated Could be seen hanging from the long process
of incus and entering the fenestra

Prof Dr Balasubramanian Thiagarajan

Ear lobe repair
Incision:
Ear lobe repair is the most common request in
cosmetic surgery. Torn ear lobes result from vari- Common incisional modalities include scar
ous forms of trauma, which include: excision with scalpel / scissors. Incision should be
performed in a pressure less manner. Radio-fre-
1. Babies pulling ear rings quency cautery has also been used for this pur-
pose. It offers precision, and simultaneous cutting
2. Entanglement in telephone cords and coagulation. The frequency used is 4.0 MHz.
Some authors also prefer using CO2 laser. Small
3. Hair brushes tears involving the upper two thirds of ear lobe
can just be incised. The enlarged fistula can be
4. Caught in the clothing repaired by approximating the lateral and medial
surfaces. It is not mandatory for converting these
5. Spousal abuse tears into a full one. Some authors prefer using
elliptical biopsy punch forceps. 6-0 silk is ideal.
6. Heavy ear rings Some of the ear lobe tears Some authors use 6-0 chromic catgut which need
occur over years of constant weight of heavy, not be removed. Incomplete tears that are at or
pendulous ear rings. Patients fail to seek immedi- below the junction of the lower third of the ear
ate care when the ear lobe is acutely torn causing lobe should be converted into a full tear. Failure
the torn edges of the lobe becoming epithelialized to include the inferior border of the lobe mar-
thus forming a fistula or cleft. gin can result in bunching and elongation of the
earlobe. When repairing full thickness ear lobe
All the currently available methods of earlobe tear a single buried 5-0 absorbable suture is used.
repair concerns the removal of the scar tissue and This reduces the dead space and diminishes the
some type of approximation of the fresh edges. tension on the skin sutures. The lateral surface
Ear lobe repair is usually performed under local of the ear lobe is sutured first, this will enable
anesthesia. 2% xylocaine with 1 in 100,000 units a minor irregularity to be hidden behind the
adrenaline is used as the local anesthetic. About earlobe. Re-piercing ear lobe: This can be done
0.5 ml of this drug is injected at the root of the immediately. This is viable because the patient
ear lobe to anesthetize the area. Since the ear can leave the OT with an ear ring which can be
lobe is the most fleshy and mobile areas of the worn throughout the healing period.
body it should be controlled and stabilized before
attempting the repair. Common stabilization mo-
dalities include the use of skin hooks, chalazion Complications:
clamps and sterile tongue blades (wooden straight
ones). 1. Depressed linear scar. This can be treated by
resurfacing with Co2 laser.

2. Inferior notching of the lobe. This is due to im-

proper alignment of the inferior lobe or from scar

Surgical techniques in Otolaryngology

98
retraction. Everting the closure and placing a key
suture will reduce the incidence of this complica-
tion.

Prevention of ear lobe tears:

1. Avoid wearing heavy ear rings for long periods

of time
Image showing Chalazion clamp
2. The ear rings can be removed while using the
phone

3. Ear rings to be removed when in saloon

4. Children should not be allowed to wear small

loop or dangling ear rings

5. Ear rings are ideally removed before taking off

the upper clothing.

Image showing earlobe tear

Prof Dr Balasubramanian Thiagarajan

Image showing scar in the lobule removed

Image showing lateral surface of the ear lobule

wound sutured.

Surgical techniques in Otolaryngology

100
Canalplasty 2. The posterior wall and floor of the canal is
supplied by the auricular branch of vagus (Arnold
nerve)
Introduction:
3. The tympanic plexus also supplies some areas
A canalplasty is usually performed to widen a
Blood supply:
narrowed external auditory canal either due to
congenital / acquired causes. The reasons for per-
1. Posterior auricular artery
forming this procedure are as follows:
2. Deep auricular branch of the maxillary artery
1. To improve access to middle ear and mastoid
cavities during mastoid surgeries
3. Superficial temporal artery
2. To remove bony / soft tissue growths / scar
tissue occluding the external canal
Important anatomic relations that should be
3. To treat aural atresia
borne in mind during surgery:

Anterior to the bony portion of external auditory

canal lie the temporomandibular joint and the
Anatomy:
parotid gland. During canalplasty care should be
taken not to injure these structures. Posterior and
The adult external auditory canal is about 2.5
inferior to the bony external canal lies the mas-
cms long and is composed of lateral cartilaginous
toid portion of the temporal bone and it contains
(1/3) and medial bony (2/3) portions.
the facial nerve. Facial nerve courses usually
lateral to the annulus in the posteroinferior quad-
The medial bony portion of the external canal
rant of the tympanic membrane.
consists of the tympanic bone which is a ringed
lateral projection of temporal bone. There is a
Function of external canal:
notch in the superior portion of the tympanic
bone known as the notch of Rivinus which is
1. It serves as efficient conduit for transmission of
located at the junction of tympanosquamous and
sound from the environment to the ear drum
tympanomastoid suture lines.
2. Protects the middle ear and inner ear from
Sensory innervation of external auditory canal:
environmental insults
1. Auriculotemporal nerve (from the mandibular
Indications:
branch of the trigeminal nerve) provides sensory
innervation to anterior, posterior walls and the
1. Hearing loss due to the presence of osteoma
roof of external canal.

Prof Dr Balasubramanian Thiagarajan

 Approaches:
2. To improve self cleansing mechanism of exter-
nal canal in the presence of exostosis The following approaches are possible:

3. To improve visualization of ear drum while 1. Endomeatal

performing tympanoplasty
2. Post aural
Contraindications:
3. Endomeatal Typically a postaural approach
1. Presence of acute infections in the external combined with endaural incision is used to re-
auditory canal move exostosis and medial canal fibrosis.

Endaural / endomeatal incision may be preferred

for osteoma as they often have a stalk that facil-
Planning: itates easy removal. Endaural incision is made
in the external canal as far medial as possible. A
If otitis externa is present then the patient should laterally based vascular strip is developed in the
be treated for the same by administration of topi- external auditory canal skin. After completion
cal antibiotic ear drops. A combination of antibi- of this step the post aural incision is given. It is
otic and steroid ear drops would actually help. usually given 7 mm behind the post aural sulcus.
The incision is continued through the auricularis
Anesthesia: posterior muscle down to temporalis fascia. Peri-
osteum over the mastoid is incised and elevated
This surgery is ideally performed under general anteriorly to the external canal. The endaural
anesthesia. In congenital external canal atresia incision is found from the post aural approach,
facial nerve monitoring is used and hence long and the two incisions are joined. The external au-
acting paralytics should not be used. Xylocaine ditory canal skin is carefully elevated off the bony
1% mixed with 1 in 100,000 adrenaline is used to external canal and then retracted forward with
infiltrate the external canal. Infiltration is usually the auricle. In external canal exostosis, the skin
given in the cartilaginous, hair bearing portion of over the exostosis is elevated with a round knife
the external canal. This is done to reduce bleeding and elevated toward the ear drum. The exostosis
during the procedure. is drilled down using a cutting / diamond burrs
in a lateral to medial direction. Curettes can also
Patient positioning: be used to dissect bony edges. Canalplasty for
acquired external canal stenosis needs drilling of
The patient is ideally positioned supine on the the anterior bony canal. When drill is used care
Operating table with the head turned away from should be taken to avoid contact with the ossic-
the surgeon. The table is turned 180 degrees away ular chain as it could cause conductive hearing
from the anesthesiology team to allow proper loss. While drilling anteriorly care should be
positioning of the microscope. taken to avoid penetration into the TM joint. This
can be prevented by drilling away bone superior

Surgical techniques in Otolaryngology

102
and inferior to the temporomandibular joint first,
before carefully removing the buttress of bone
overlying the joint. After canaplasty the skin flap
is repositioned and the wound is closed in layers.
Ideally a stent may be placed to assist adherence
of the external canal skin to the external canal.

Image showing canalplasty being performed

Prof Dr Balasubramanian Thiagarajan

 These 6 hillocks eventually fuse to form the full
Preauricular sinus and its management fledged pinna.

Theories or preauricular sinus formation:

Introduction: Embryological fusion theory: This commonly
This condition was first described by Van He- accepted theory attributes the development of
usinger in 1864. He also rightly postulated it to preauricular sinus due to incomplete or defective
be congenital in nature. Most of these patients are fusion of these
symptomatic. Hillocks.
Common symptoms include infections, celluli-
tis, and abscess formation in-front of the pinna. Ectodermal infolding theory: This theory attri-
Some of these patients may have recurrent infec- butes isolated ectodermal folding during auric-
tions leading on to ular development. This theory has virtually no
embarassing discharge from the sinus. In most takers.
patients this condition is identified during routine
examination involving ear, nose and throat. Incomplete closure of dorsal part of first pharyn-
geal groove: This theory suggests that branchial
Synonyms: fistula are formed due to incomplete closure of
Various terminologies have been used to describe the dorsal part of first pharyngeal groove. This
this condition. They include preauricular pit, pre- theory assumes that preauricular sinuses form
auricular fistula, preauricular tract, helical fistulae part of branchiogenic malformations.
or preauricular cyst.
Preauricular sinus should not be confused with
Incidence:
branchial cleft anomalies. These branchial cleft
The estimated incidence as reported by studies in
anomalies are intimately related to the external
US puts the incidence somewhere between 0.1 –
auditory canal / ear
0.9%. Studies in Africa put a slightly higher figure
drum / angle of the mandible whereas the preau-
(4 – 5%).
ricular sinus are not. It has also been shown that
the preauricular sinus does not involve the facial
Embryology:
nerve or its branches, of course surgical removal
Since this condition is an embryological aberra-
of preauricular sinus may put the facial nerve at
tion, a study of development of Pinna wont be out
risk.
of place here. Studies have shown that the forma-
tion of preauricular
sinus is closely associated with the development
of pinna which occurs during the 6th week of
gestation. Auricle develops from 6 mesenchmal
hillocks known as Hillocks
of His. Three of these hillocks arise from the
caudal border of the first arch, and the other three
arise from the cephalic border of the second arch.

Surgical techniques in Otolaryngology

104
 lateral cervical fistulae, preauricular sinus, and
nasolacrimal duct stenosis and fistula.
2. Branchio oto urethral syndrome – These pa-
tients have sensorineural hearing loss, preauric-
ular sinus, renal anomalies like bifid ureters and
bifid renal pelvis.
3. Branchio otic syndrome – This is a variant of
BOR syndrome. These patients
have branchial anomalies, preauricular sinus,
branchial fistula (unilateral) with no renal dyspla-
sia
4. Branchio oto costal syndrome – These patients
have conductive deafness, preauricular sinus,
bilateral commissural lip, unilateral branchial
fistula and rib anomalies
5. Cat eye syndrome – Coloboma of iris, Preau-
ricular sinus, imperforate anus and down slanting
of palpebral fissures
6. Trisomy 22 – These patients have bilateral pre-
Image showing development of Pinna auricular sinus, anti mongoloid palpebral fissures,
macroglossia, cleft palate, enlarged sub lingual
Mode of inheritance: glands and short lower limbs

Preauricular sinus occurs either sporadically or Clinical features:

may be inherited. In about half the number of Preauricular sinus is seen as a small pit usually at
patients it occurs in a sporadic manner and com- the anterior margin of the ascending limb of the
monly on the right side. helix. In some patients this opening may also be
Bilateral cases are commonly genetically inherit- seen along the
ed. Studies have shown that inheritance is auto- postero superior margin of helix. Rarely it may be
somal dominant with varying degrees of penetra- seen close to the tragus or lobule.
tion (about 85% penetration). Studies in China
has shown chromosome 8q11 to be site of abnor- In almost all patients part of the tract blends with
mal gene which transmits preauricular sinus. the perichondrium of the auricular cartilage.
The sinus tract may follow a tortuous course.
Preauricular sinus has been described as a part of The sinus tract is usually superior and lateral to
number of syndromes. These syndromes include: the facial nerve and parotid gland. This feature
differentiates it from branchial cleft anomalies.
1. BOR syndrome (Branchio oto renal syndrome) Sometimes the preauricular sinus may lead to the
– defects in these patients include outer, middle formation of subcutaneous cyst that is intimately
and inner ear deformities with conductive deaf- related to the tragal cartilage and the
ness. These patients also have renal anomalies, crus of helix.

Prof Dr Balasubramanian Thiagarajan

Patients usually present with discharge from the
preauricular sinus pit. Discharge could be due
to desquamating epithelial debris or infection.
Studies have shown that the common pathogens
causing infection in the preauricular sinus in-
clude staphylococcus, Proteus, streptococcus and
peptococcus.

It is always better to rule out syndromes associ-

ated with preauricular sinus. Almost majority of
these syndromes involve kidney. There is intense
debate raging whether ultrasound examination
should be performed as a routine in all patients
with preauricular sinus. Considering the com-
monality of the lesion and the cost and time
involved routine ultrasound in these patients are Image of a child with preauricular sinus
not indicated. Wang et al of California came out
with a set of indications when ultrasound abdo-
men should be performed in these patients.
Complications of preauricular sinus:
Wang’s criteria in performing ultrasound exam-
ination in patients with preauricular sinus: Infection is the predominant complication. In the
acute phase of infection (cellulitis stage) man-
1. Presence of another malformation / dysmor- agement is by prescribing appropriate antibiotics
phic feature in adequate doses. Since the common infecting
2. Family history of deafness organism is staphylococcus aureus the drug of
3. Malformations involving pinna choice is a combination of amoxycillin and clavu-
4. Maternal history of gestational diabetes lanic acid.

Pure tone audiometry: Abscess formation:

This is another investigation that should routinely
be performed in all patients with preauricular Abscess in this area should always be drained.
sinuses. Incision and drainage using a scalpel would cause
extensive fibrosis causing difficulty in complete
surgical clearance of the area at a later date.
Precisely for this reason Coatesworth et al de-
scribed a drainage procedure using lacrimal
probe. This probe negates the need for incision in
this area and thus causes very little disturbance
to the underlying preauricular sinus tissue. In

Surgical techniques in Otolaryngology

106
this technique of drainage the overlying skin is
anesthetized using 2% xylocaine infiltration. The
blunt end of the lacrimal probe is inserted into
the sinus through the pit. This allows drainage to
occur via the normal opening which is usually
present in front of the ascending limb of the helix.
If preauricular abscess does not drain when this
technique is used then conventional incision and
drainage should be performed. Recurrent infec-
tions involving the preauricular sinus should be
managed by complete surgical resection of the
sinus tract completely during the stage of quies-
cence.

Image showing common sites of preauricular

sinus involvement
1. Anterior margin of ascending limb of helix
(most common)
2. Superior to auricle
3. Along the posterior surface of cymba concha
4. Lobule
5. Posterior to auricle

Image showing lacrimal probe which is used to Surgical excision of preauricular sinus:
drain preauricular abscess
While surgically excising the sinus tract care
should be taken to completely remove it. Incom-
plete removal of sinus tract is the commonest
cause for recurrence. The recurrence rate ranges
between 1 – 45% depending on the procedure
followed.

Prof Dr Balasubramanian Thiagarajan

Simple sincectomy:

This is the commonly used standard procedure

for excising preauricular sinus. An ellipse of skin
surrounding the preauricular sinus tract is ex-
cised and dissected out
along with the tract. The tract can simply be iden-
tified by its glistening white color, or methylene
blue dye can be injected through the opening to
facilitate easy identification of the tract. Most of
these fistulae follow the external auditory canal.

This procedure can be performed under local or

general anesthesia. While operating on children
general anesthesia is preferred.

Jensma technique:
This technique was popularised by Jensma in
1970. It is actually a modification of the classic Image showing the incision marked around the
sinusotomy procedure. This technique is also preauricular sinus opening.
known as inside out technique.

Procedure:
A small skin incision around the sinus is made.

Stay sutures are placed to allow retraction of the

tract to facilitate surgical extirpation. The sinus is
opened with a sharp scissors.

Under magnification the glistening lining which

is inside and the outer wall of the tract are dis-
sected free from the surrounding tissue.

Image showing sinus opened with a sharp scis-

sors

Surgical techniques in Otolaryngology

108
 The main advantage of this procedure is that
the sinus can be viewed and followed from both
inside and outside. The classic procedure allows
visualization of the sinus from only outside. All
the tracts are opened and followed until the dead
end is reached. A lacrimal duct probe can be used
to establish the direction of small tracts.
It should be borne in mind that one of the tracts
could be closely adherent to the perichondrium
of the root of the helix / tragus. This piece of
perichondrium along with a small bit of under-
lying cartilage should be resected along with the
specimen.

The medial limit of dissection is always the

temporalis fascia. Before closure the wound bed
should be carefully examined for evidence of
residual tracts.

Causes of recurrence:

1. Major cause of recurrence is inadequate remov-

al of the mass.
2. Performing the surgery without magnification
aids
3. Skill of the operating surgeon. This is rather
important because surgeons consider this case to
be a minor procedure and hence pass it on either
to a novice or junior surgeon who may not be
experienced enough in performing this type of
surgery.

Supra auricular approach:

This is a more radical approach. Major advantage

of this approach is that it gives excellent exposure
and hence removal of the sinus tract is nearly
complete. This procedure has the lowest recur-
rence rate among all other surgical procedures for
preauricular sinus removal.

Prof Dr Balasubramanian Thiagarajan

This procedure involves a post auricular exten-
sion of the elliptical incision around the preau-
ricular sinus opening. The incision is deepened
till the temporalis fascia comes into view. This is
supposedly the medial limit for resection in this
procedure. All the tissue superficial to the tem-
poralis fascia is removed together with the pre-
auricular sinus. A portion of the cartilage along
the base of the preauricular sinus should also be
excised. The dead space should be closed in layers
and compression dressing should be applied. A
drain need not be placed here.

Image showing the bed after excision of preau-

ricular sinus. Note the cartilage of helix after
removal of the preauricular sinus.

Image showing incision for supra auricular

approach

Image showing closure of wound after preauric-

ular sinus excision.

Surgical techniques in Otolaryngology

110
Labyrinthectomy Trans canal labyrinthectomy:

This is an effective option for the management of

Introduction:
poorly compensated unilateral peripheral vestib-
ular dysfunction in the presence of ipsilateral pro-
Labyrinthectomy is an effective surgery for
found sensorineural hearing loss. This technique
managing poorly compensated unilateral pe-
was first introduced in 1950’s by Schuknecht and
ripheral vestibular dysfunction in the presence of
Cawthrone.
non-serviceable hearing ear. Relief from vertigo is
achieved at the expense of residual hearing in the
Advantages of trans canal labyrinthectomy:
ear operated. This procedure is strictly reserved
for patients with non-serviceable hearing.
1. It is less invasive than transmastoid labyrin-
thectomy
Principle:
2. It provides direct approach to vestibular end
organ
The principle is to open all the three semicir-
3. The operating time is shorter when compared
cular canals and vestibule with preservation of
to that of transmastoid labyrinthectomy
landmarks till the end of the procedure. After
4. It has lesser morbidity than transmastoid ap-
exposure of all the ampullae of the semicircular
proach
canals and vestibules the five individual groups of
The main disadvantage of this approach is that
sensory epithelia are excised under direct vision.
the exposure is highly unlimited.
This procedure eliminates abnormal vestibular
input from the affected ear.
There is significant incidence of incomplete lab-
yrinthectomy if the surgeon is not experienced.
Indications:
Reaching the ampulla of the posterior canal is dif-
ficult because it is performed with blind probing.
1. In order to approach internal acoustic meatus
in acoustic schwannoma surgery
It should be stressed at this point that vestibular
2. Unilateral vestibular dysfunction with non-ser-
disorders should be given appropriate medical
viceable hearing
treatment and reconditioning exercised before
3. Severe and intractable Meniere’s disease
embarking on labyrinthectomy.
Techniques:
In patients with bilateral vestibulocochlear disor-
ders alternate techniques of labyrinthine destruc-
Two techniques can be used for labyrinthectomy.
tion should be considered before surgery.
1. Trans canal labyrinthectomy
2. Trans labyrinthine labyrinthectomy

Prof Dr Balasubramanian Thiagarajan

Indications for transmastoid labyrinthectomy: Trans canal approach:

1. Delayed onset vertigo syndrome In this procedure an anteriorly based tympano-

2. Unilateral severe Meniere’s syndrome meatal flap is elevated and the posterior aspect of
3. Trans canal labyrinthectomy failures the tympanic annulus is curetted to visualize the
foot plate of stapes. Curetting of the tympanic
Contraindications for labyrinthectomy: annulus should be continued till the horizontal
segment of facial nerve; stapes foot plate and
1. If the affected ear is the only hearing ear round window area should be fully visible.
2. If the patient has serviceable hearing
3. Patients with poor surgical risk

Anesthesia:

This procedure is ideally performed under gener-

al anesthesia. Local anesthesia is not advisable
because of violent reactions that could accom-
pany vestibular ablation. Of course revision
labyrinthectomy in an ear with minimal residual
vestibular function can be performed under local Image showing Reverse Trendelenburg position
anesthesia.
The incus is removed first. The stapedius muscle
Position: tendon is cut and the supra structure of stapes is
removed carefully. Small curettes are used to en-
The patient is placed in supine position, with large the oval window in its anterior and inferior
reverse Trendelenburg tilt and the neck extended. aspects. The promontory between the oval and
The head is turned away from the surgeon, with round windows are drilled in order to connect
the ear to be operated facing up. both the oval and round windows.

Close to the posterior end of the round window

The head is turned away from the surgeon, with niche, the posterior ampullary nerve can be ex-
the ear to be operated facing up. The patient is posed and sectioned. The vestibule and basal turn
draped with a craniotomy type drape that has a of cochlea are exposed widely to create a common
large window to visualize the face. cavity. The utricle and saccule are scraped from
the walls of the vestibule by using a right-angled
Technique: pick. Probing is done to determine the locations
of ampullae of semicircular canal.
Trans canal approach is preferred unless the pa-
tient has a narrow meatus. After destruction of the end organ, the vestibule
must be filled with gelfoam (soaked in gentamy-

Surgical techniques in Otolaryngology

112
cin / streptomycin. Ear lobe fat can also be used
to fill the cavity in lieu of gelfoam. Transmastoid approach:

CSF leaks if any should be repaired with tissue In this approach a post aural incision is used to
seal. The tympanomeatal flap can be replaced expose the mastoid bone. Cortical mastoidectomy
against the posterior canal wall and the ear canal is performed with a largest possible cutting burr.
is packed with gelatin foam. The aditus is identified and widened. The short
process of incus comes into view.

The superior and posterior peri labyrinthine air

cell tracts and retro facial air cells are removed
carefully to skeletonize the bony labyrinth. The
facial nerve should be identified. The tegmen
mastoideum is thinned out using a diamond burr.
Usually medium cutting burrs are preferred on
the bony labyrinth because the bone is very hard.

Continuous suction irrigation is used to remove

bone dust as drilling is continued. Care should be
taken to provide continuous irrigation when the
area over facial nerve is drilled. Labyrinthectomy
is started by drilling over the superior aspect of
Image showing tympano meatal flap being the lateral canal anteriorly and
elevated. drilling is carried out towards the posterior canal.
The lateral canal appears as a blue line.

It is opened along its superior surface. The infe-

rior surface should be preserved as a landmark
for the facial nerve. The drilling is continued in
the posterior direction to open up the posterior
canal. The drilling is continued superiorly until
the common crus and superior canal is identified
and opened. The neuroepithelia of the superior
and lateral ampulla is identified anteriorly and the
dense labyrinthine bone is removed to open up
the vestibule.

Image showing Foot plate of stapes and Round

window

Prof Dr Balasubramanian Thiagarajan

 Post op follow up:
The posterior canal is followed inferiorly and
medial to the facial nerve to visualize the poste- Post op antibiotic is required. Anti-emetic should
rior canal ampulla. The portion of the posterior be given routinely until nausea and vomiting
canal extending under the genu of the facial ceases. Vestibular sedatives may also be needed in
nerve should ideally be drilled with a diamond some patients for a few weeks.
burr. The horizontal segment of the facial nerve is
skeletonized. Bandage can be removed / changed after 24
hours. Sutures can be removed on the 7th post-
While performing labyrinthectomy bone should operative day. Patients should be gradually
be preserved in the following regions: mobilized and physiotherapy exercises should be
started. Patients should be encouraged to walk
• Over the inferior wall of lateral canal, to protect and take an active role in mobilization.
the second genu of facial nerve
• Over the inferior wall of the posterior canal to Patients should not drive until they are free
protect a high jugular bulb from attacks of spontaneous vertigo for at least 3
• Over the medial wall of the superior canal am- months.
pullae, to protect the facial nerve anterior to the
superior vestibular nerve at the fundus of internal
auditory canal
The surgery is complete when the neurosensory
epithelium of the three ampulla, utricle, and sac-
cule are visualized.

After exposing all five portions of neurosensory

epithelium, they should be removed with a sickle
knife taking care not to rupture the underlying
bony cribrosa.

Penetration in the cribrosa area can cause CSF

leak. If there is a CSF leak it should be immedi-
ately repaired with a soft tissue seal on the table
itself. Image showing all the components of labyrinth
opened up.
Attempt should always be made to remove ev-
ery vestige of neuroepithelium because a viable Complications:
remnant may give rise to spontaneous neuronal
activity with continuing vertigo. Mastoid cavity is CSF leak can occur when the cribrosa is frac-
closed in layers. tured. This can be managed by sealing the vesti-
bule with tissue graft / subcutaneous tissue.

Surgical techniques in Otolaryngology

114
Failure to locate the utricle is a possible compli-
cation. While aspirating the peri lymphatic fluid
from the vestibule, the utricle usually retracts
superiorly to lie medial to the horizontal segment
of the facial nerve. This situation can be managed
by the use of utricular hook.

Removing bone from the inferior aspect of the

oval window and connecting it to the round win-
dow improves access to the vestibule.

The horizontal segment of facial nerve may be

injured during trans canal labyrinthectomy.

Prof Dr Balasubramanian Thiagarajan

 cartilage into the posterior meatus
Meatoplasty 2. Excess underlying bone of the posterior bony
meatus
Introduction: 3. Inadequate meatal skin circumference. This
could predispose to stenosis leading to wound
In advanced middle ear infections and cholestea- disruption and infection.
toma a canal wall down mastoidectomy needs to
be performed with an intention of eradicating the Types of approaches used for meatoplasty:
disease process completely. At the end of canal
wall down procedure meatoplasty need to be per- 1. Endaural approach
formed. Meatoplasty is performed to widen the 2. Retro-auricular approach
external auditory canal and to make it continuous
with the middle ear and mastoid cavity. Stacke Meatoplasty:

Advantages of a wide meatoplasty include: This uses the endaural approach. An inferiorly
based posterior canal skin flap is created. A radial
1. Provides adequate ventilation to the mastoid incision is given at 12 o clock position cutting the
cavity and middle ear there by preventing bacte- posterior canal wall skin. A medial circumfer-
rial ential incision is given 2-3mm lateral to the ear
growth. It also reduces conditions favorable for drum. Lateral circumferential incision is provided
growth of pathogenic bacteria. through conchal skin. A strip of conchal cartilage
2. Debris accumulation can be easily identified is cut. Temporalis fascia flap should cover the
during regular followup and cleaned. entire facial ridge and inferior part of the cavity.
3. It helps the surgeon in identification of resid-
ual / recurrent pathology in the middle ear and Surdille flap:
mastoid
cavity This flap uses endaural approach. Circumferential
4. It supports rapid epithelialization and exterior- incision is given laterally in the external canal
ization of the mastoid bowl. skin leaving a larger TM flap and a smaller lateral
flap known as the Surdille’s flap. The Surdille flap
One major draw back of a very large meatoplasty is pushed posteriorly into cavity and held in place
is that it could cause misshape the ear making it by a BIPP pack. Superiorly, anterosuperior flap
look rather unnatural. Therefore, a balance should covers the attic and tegmen and inferiorly tympa-
be struck to create a wide enough meatoplasty to nomeatal flap covers the aditus and antrum.
fulfill the ventilation requirements and it should
not cause any distortion to the shape of the pinna.

Problems that need to be addressed by meatoplas-

ty:

1. Projection of the anterior edge of the conchal

Surgical techniques in Otolaryngology

116
Image showing Surdille flap
Image showing Lempert incision

Farrior meatoplasty:
Korner Meatoplasty:
This meatoplasty is performed via endaural ap-
This meatoplasty can be performed either by proach. In this type of meatoplasty a conchal ear
endaural or post aural approach. If endaural canal skin flap is created.
approach is preferred then Lempert / Heerman II
incision is preferred. In Heerman’s incision two Fleury meatoplasty:
radial incisions are given in the external auditory
canal at 6&12 o clock positions. A circumferential This type of meatoplasty is performed endaurally.
incision is used to joint these two incisions close It is a superior based vascular flap with a lateral
to the ear drum. circumferential incision starting at the 2 o clock
position.
These incisions divide the flap into medial tym-
panomeatal flap and a lateral korner’s flap. The
Korner’s flap is pushed posteriorly into the sur-
gical cavity and is held in position with a BIPP
pack.

Superiorly, anterosuperior flap covers the attic

and tegmen, while inferiorly the tympanomeatal
flap covers the aditus and antrum.

Prof Dr Balasubramanian Thiagarajan

 Image showing Fleury incision

Image showing Farrior meatoplasty incisions: Fleury incision has two components. One
circumferential incision to elevate tympanome-
1. Anterior circumferential incision at 4 o clock atal flap medially and a vertical incision at 10 o
positions clock position as shown above.
2. Posterior circumferential incisions
3. Vertical incisions
4. Anterior vertical incisions Large lateral flap of Surdile is created. This flap is
5. Posterior vertical incisions made to cover the facial ridge & lower part of the
6. Lateral incision – This allows further eleva- mastoid cavity. The vertical incision (skin) is su-
tion of skin tured first. It pulls the upper part of pinna further
upwards.

Skin over the conchal cartilage is elevated and a

strip of conchal cartilage is exposed. The conchal
cartilage is resected leaving behind the perichon-
drium. The folded skin is sutured to cover the
remaining exposed conchal cartilage.

Portman’s small 3 flap meatoplasty:

This flap is created via post aural approach. Fea-

tures of this meatoplasty are:

Surgical techniques in Otolaryngology

118
1. Three flaps are created i.e. lateral, superior, and
inferior Portmann’s large 5 flap meatoplasty with removal
2. There is no removal of conchal cartilage of cartilage:
3. Very useful for small cavities
4. Lateral circumferential incision from 12 to 6 The ear canal skin is divided at 9 o clock position.
o clock position is made 10 mm lateral to upper
tympanic membrane Laterally at the conchal cartilage the following
5. Upper lateral incision from the upper part of incisions are given:
circumferential incision to the spine of Henle
6. Similar lower incision from inferior edge of 1. One incision that turns infero anteriorly
circumferential incision towards the concha 2. One incision that turns supero anteriorly
This results in lateral, superior and inferior flap.

Image showing Portmann’s incision

A finger is placed through the canal exposing the

lateral flap. The flap is thinned out. When flap
elevation is complete, the conchal cartilage would
be visible. The flap is turned around the cartilage
and fixed to posterior aspect of the cartilage. This Image showing Portmann Y flap incision
flap will form lateral covering of the cavity and
facial ridge.

Ear canal skin is divided at 9 o clock position

up to the ear drum. This creates a superior flap
which covers the superior part of the cavity and
inferior flap which covers the facial ridge. Both
these flaps need to be thinned out.

Prof Dr Balasubramanian Thiagarajan

 conchal skin, cartilage and post auricular soft tis-
sue. This divides the lateral skin flap into superior
and inferior. Through retro-auricular approach
the conchal cartilage is exposed and excised. The
superior and inferior flaps are inverted onto the
posterior aspect of remaining conchal cartilage.

Image showing 5 flaps elevated

Superior and inferior flaps are further divided lat-

er. Conchal skin of lateral flap is elevated from the
cartilage. A triangular piece of cartilage is re-
moved. Skin from other two conchomeatal flaps
are also elevated.
Image showing incisions used for Sheehy meato-
To facilitate mobility of these two flaps, a trian- plasty
gular skin is removed from their tips. A total of
5 flaps are created. The created flaps are thinned 1. A vertical intercartilaginous incision at 12 o
out and sutured to the posterior aspect of concha clock position extending through skin, subcutis
with a single suture. The cavity is packed with down to the bone.
BIPP. 2. Another incision at 5 o clock position into
the conchal cartilage (indicated by the arrow)
Sheehy Meatoplasty: 3. Horizontal antero posterior conchal incision
at about 9 o clock position creating two concho-
This again is performed via the post aural inci- meatal flaps.
sion.
A vertical intercartilagenous incision at 12 o clock Fisch meatoplasty:
position is given parallel to the crus of helix. This is also performed via post aural incision.
Another incision is made at 5 o clock position One antero posterior incision is given over the
into the conchal cartilage. A horizontal incision conchal cartilage. The skin flap is elevated from
passes backward at 9 o clock position through the concha before resecting a major portion of the

Surgical techniques in Otolaryngology

120
cartilage. and periosteum are elevated and constitute a large
palva flap.
The two liberated flaps are inverted posteriorly Another incision is made along the entrance of
around the edge of the concha and sutured to the canal from 6 to 12 o clock through subcutane-
posterior aspect of concha creating a meatoplasty. ous tissue and periosteum.

Meatoplasty is performed by turning the pinna

backwards, making an intercartilaginous incision
at 12 o clock position and an incision through
conchal cartilage at 5 o clock position. Auricle
is pulled forwards and a large strip of conchal
cartilage is excised. Korner’s flap is turned around
resected, conchal and palva flap is elevated.

A radial incision is made at 9 o clock position

through the canal elevating an inferior and
superior canal skin flap. After canal wall down
mastoidectomy the modified palva flap is placed
in the cavity attached anteromedially and infero
anteriorly. This flap mainly obliterates the posteri-
Image showing incision for Fisch meatoplasty. or part of the cavity and sinodural angle.
The green shaded area indicates the amount of
conchal cartilage that is usually removed.

Landolfi’s modified Fisch technique:

An antero posterior incision is given.

Skin flap is elevated from the conchal cartilage
The conchal cartilage is exposed using scissors
the conchal cartilage is resected including the
anterior edge of crus of helix.

The conchal skin is inverted to provide epithelial

covering for the lateral wall of the mastoid cavity.

Palva flap:

This is actually a subcutis muscle clap. This has

a dual role of creating a wide meatoplasty and
cavity obliteration. This procedure is done via
post aural incision. The skin, subcutaneous tissue

Prof Dr Balasubramanian Thiagarajan

 Indications:
Retrolabyrinthine approach to petrous
apex 1. Resection of CP angle tumors

2. Resection of petrous ridge tumors

This approach is considered to be the unsung
hero of skull base surgery. This technique is
3. Vestibular neurectomy
ideally suited for patients with pathologies in-
volving the posterior cranial fossa with retained
4. Partial resection of the sensory root of 5th
hearing. Directly accessing the Cerebellopontine
cranial nerve
angle through temporal bone and avoiding neural
structures preserves hearing. This approach al-
5. Fenestration of symptomatic arachnoid cysts
lows for mobilization of the sigmoid sinus pos-
teriorly and access to the posterior fossa through
6. Meningiomas
the presigmoid space. This approach provides
excellent exposure laterally from the 4th cranial
7. Metastatic lesions
nerve to the upper border of the jugular tubercle.
There is only limited access to the ventral brain
8. Biopsy of brain stem lesions
stem and clivus.
9. In conjunction with other approaches in exten-
Factors that limit this approach:
sive skull base surgeries
1. Poorly pneumatized mastoid
Procedure:
2. Forward lying sinus
This surgery is performed under general anesthe-
sia. Patient is placed supine. Surgeon should be
3. High jugular bulb
seated comfortably during surgery. The patient’s
head is rotated 70° away from the surgeon. Hair is
4. Low lying tegmen
removed about 4 cms superiorly and post auricu-
larly in order to site the incision.
This approach can be used by itself for small tu-
mors or in conjunction with other techniques to
Facial nerve monitoring electrodes should be
gain greater exposure. These combined approach-
placed and verified for its function. Abdomen is
es include:
also prepared to harvest abdominal fat. Preopera-
tive antibiotics are also administered on the table.
Translabyrinthine approach Infratemporal ap-
Before starting the surgery, Intravenous mannitol
proach Trans cochlear approach Combined trans
and frusemide are administered to bring down
temporal approaches Retro sigmoid craniotomies.
the intracranial tension.

Surgical techniques in Otolaryngology

122
Incision:
Linea temporalis
A C shaped incision is made with a 15-blade
scalpel 3-4 cm posterior to the post aural crease Mastoid emissary foramen
extending up to the mastoid tip.
Asterion

Henle’s spine

The following triangles should be identified be-

fore actual drilling starts:

Fukushima outer mastoid triangle:

Three points of this triangle include:

• Posterior root of zygoma

• Asterion

Image showing incision for retrolarybrinthine • Mastoid tip

approach.

Skin and subcutaneous tissue flap is elevated an- Fukushima Inner triangle (Trautmann’s triangle)
teriorly up to the external acoustic meatus. Next
an offset incision is created through the tempora-
lis muscle, fascia and periosteum. This helps later • Anterior – Superior (anterior) semicircular
during wound closure as the wound can be closed canal
in layers. This layered closure helps in prevention
of CSF leak. • Superior – Superior petrosal vein

A periosteal elevator is used to elevate the perios- • Lateral – Sigmoid sinus

teum away from the cranium exposing the mas-
toid cortex. The following bony landmarks need • Inferior – Jugular bulb
to be identified:
McEwen’s triangle:
Root of the zygoma
• Flat triangle behind the external auditory canal
External auditory meatus

Prof Dr Balasubramanian Thiagarajan

Image showing the various triangles around
mastoid bone Image showing posterior fossa dura area that
needs to be drilled to expose endolymphatic sac
Bone over the Fukushima’s outer triangle is
drilled out using a cutting burr. Under magnifi- A 11 blade and micro scissors is used to open the
cation a complete mastoidectomy is performed. dura anterior to sigmoid sinus. It is opened with
Proper size diamond burr bit is used to remove an anteriorly based C shaped flap as shown below.
bone overlying middle cranial fossa dura, sigmoid
sinus and posterior fossa dura. Maximal exposure The endolymphatic sac would be visualized infe-
of dura could be obtained by skeletonizing the rior to the posterior canal as a thickened area of
sigmoid sinus and jugular bulb completely. The dura. The dural flap is secured with stay sutures
lateral semicircular canal and posterior semicir- for better exposure. A neurosurgical cottonoid
cular canal should be well defined. patty is placed over the brain stem. This produces
a small amount of tension between the cerebel-
The entire course of mastoid segment of facial lum and the petrous ridge. The arachnoid adhe-
nerve should also be deroofed. Sinodural angle sions in this location are transected and CSF is
dura should also be exposed by careful drilling released. This causes the cerebellum to fall away
in the area. Bone over the posterior fossa dura from the petrous ridge allowing better visual-
between the posterior semicircular canal and ization of the CP angle. Posterior face of petrous
the sigmoid sinus should be removed with blunt ridge, and cranial nerves 7 and 8 in the center
dissection. Care must be taken to protect the of the field. In addition, this exposure provides
underlying endolymphatic duct and sac. Using access to the Cranial nerve 5 anteromedially.
gelfoam aditus and mastoid antrum is packed. Cranial nerves 9, 10, and 11 lie inferolaterally. It
The mastoid cavity should be copiously irrigated should be noted that the rostral division of the
with bacitracin solution in order to remove any anteroinferior cerebellar artery is associated with
bone dust that may be present there. the 7th and 8th cranial nerves. After comple-
tion of the procedure, meticulous hemostasis is
secured. The dural flap is approximated with 4-0
braided suture. The aditus, antrum, facial recess

Surgical techniques in Otolaryngology

124
and retrofacial air cells are covered with tempora-
lis fascia. The entire mastoid cavity is obliterated
using abdominal fat graft to prevent CSF leak.
The wound is then closed in layers.

Image showing endolymphatic sac being exposed Image showing structures seen after reflecting
posterior fossa dura
Complications:

1. Bleeding from dural venous sinuses

2. Cerebellar edema

3. Injury to cochlear nerve

4. Injury to facial nerve

5. Injury to intracranial blood vessels

6. CSF leak

7. Post op head ache

8. Conductive hearing loss if bone dust is not

properly removed by irrigation, or if the abdomi-
nal fat graft herniates into the middle ear cavity.

Prof Dr Balasubramanian Thiagarajan

 enable the arcuate eminence to be identified. At
Middle Cranial Fossa approach to Pe- this point the superior semicircular canal dehis-
cence
trous Apex
may clearly be visualized. The canal is opened
using diamond drill and then it is plugged. The
Introduction: canal may additionally be capped / resurfaced
using bone pate, bone
This surgical approach provides access to the wax or hydroxyapatite cement. Some surgeons
lateral skull base which includes the cranial side prefer to use soft tissue for the purpose of resur-
of petrous bone, internal auditory canal, genicu- facing the superior canal.
late ganglion of facial nerve and the petrous apex.
This classic neurosurgical approach was described This approach provides direct access to the ar-
way back in 1891 by Frank Hartley. He used the cuate eminence without the need for removing
intracranial, extradural approach to access tri- labyrinthine bone and exposure of the surround-
geminal ganglion to block ing skull base area.
it as a treatment of trigeminal neuralgia. The
overall morality in his hands was around 10%. Resurfacing of the dehiscent canal also prevents
chronic stimulation from the pulsating temporal
Cushing modified this approach slightly by min- lobe of brain.
imizing traction on the brain and also reduced
hemorrhage from middle meningeal artery by 2. Internal auditory canal decompression for:
providing less traction. This effort lowered the Skull base dysplasias (hyperostosis cranialis in-
mortality rate. The first authentic description of terna with encroachment of the internal auditory
this procedure as an approach to CP canal due to hyperostosis causing function loss of
angle was from the work of RH Parry 1904. He facial or vestibulocochlear nerves.
used this approach to section the vestibular nerve
as a treatment for intractable giddiness. William Facial nerve schwannomas
House popularized this approach by routinely
performing it to decompress internal auditory 3. Supralabyrinthine cholesteatomas
canal for cochlear otosclerosis. It was House who 4. Meningoencephalocele
first used this approach to perform removal of 5. CSF leak repair either during primary surgery
acoustic neuroma in 1961. or in the case of failed Transmastoid
surgery either intradural or extradural.
Indications: 6. Cholesterol granulomas / congenital cholestea-
toma of petrous apex
This surgical approach can be used for a variety of 7. Removal of a wide number of neurosurgical
indications which include: lesions
1. Resurfacing technique for superior semicircu- 8. Small tumors (>15mm) primarily located in
lar canal dehiscence syndrome. Middle cranial the internal auditory canal with serviceable hear-
fossa approach for managing this condition was ing (class a or b).
first described by Minor et al. A 4x4 cm craniot-
omy is drilled. The temporal lobe is retracted to

Surgical techniques in Otolaryngology

126
 Arterial line should be started to monitor real
Preoperative evaluation: time blood pressure.
Patient should be catheterized in order to accu-
1. Pure-tone audiogram and speech audiogram. rately maintain fluid balance.
This helps in ascertaining whether the patient has Perioperative antibiotics need to be administered
serviceable hearing or not. (cefazoline / amoxycillin/clavulanic acid) and
2. HR CT scan. This is performed for diagnostic they should be continued for 1 week postopera-
purposes as in the case of bone dysplasias and tively.
superior canal dehiscence syndrome. Hydrocortisone administration intravenously
3. MRI scan with gadolinium if neuronitis / ede- is advisable in the event of intraoperative nerve
ma which is specific for evaluation of facial nerve. manipulation.
When gadolinium contrast is used, then normal
facial nerve enhances faintly in the geniculate Procedure:
ganglion area, tympanic and mastoid segments.
The cisternal, intracanalicular, labyrinthine and The hair over the temporal region is shaven and
parotid segments of the nerve do not normal- the surgical field is sterilized.
ly enhance. Enhancement of the nerve in these The head is fixed in a skull clamp. Patient is
regions should cause suspicion of inflammatory / positioned with 3-point body straps in order to
neoplastic process involving the nerve. Asymmet- allow easy rolling of the bed of the patient during
ric enhancement / thickening of the tympanic / surgery to improve exposure.
mastoid segments relative to the contralateral side Electrodes are placed to monitor facial nerve and
should be considered as abnormal. In Bell’s palsy, auditory brain stem response is also recorded by
MRI with gadolinium contrast demonstrates placement of electrodes in real time. To monitor
enhancement of the intracanalicular and labyrin- facial nerve electrodes are placed over orbicularis
thine segments of the facial nerve. There is also oculi and orbicularis oris. The ground electrode is
greater degree of enhancement of the geniculate placed on the chest. ABR click generator is placed
ganglion, tympanic and mastoid segments. over the operative side ear canal. The ABR elec-
4. Diffusion weighted MRI scan in patients with trodes are placed one on each mastoid and one
supralabyrinthal / congenital apex cholesteato- over the vertex.
mas.
5. Sequential brainstem-evoked auditory poten- Two incisions can be used.
tials can be used to detect subclinical auditory
nerve damage 1. Anterior/inferiorly based skin flap. This inci-
6. Vestibular function testing sion starts anterior to tragus, extending posterior-
ly to about 3-4 cms posterior to pinna, superiorly
Anesthetic considerations: 5-6 cm, and anteriorly again to the temporal hair
General anesthesia is preferred with orotracheal line. This incision is good for extended middle
intubation. Short acting non depolarizing cranial fossa approaches. The temporalis muscle
muscle relaxant should be used to facilitate nerve is reflected inferiorly.
monitoring equipment usage. 2. Posteriorly based skin flap. This incision starts
just behind the temporal hair line and a rounded

Prof Dr Balasubramanian Thiagarajan

box shape approximately 6 cm wide is carried
back to approximately 6-7 cms. The incision is be- Elevation of muscle flap:
gun as low onto the pinna as possible. Temporalis
muscle flap is reflected anteriorly. If the skin flap is posteriorly based then anteriorly
based temporalis flap is elevated. If the skin flap
is anterior based then temporalis flap should be
inferior based. The surgeon should
be able to see the root of zygoma easily after ele-
vation of muscle flap.

Craniotomy:

Before proceeding on to craniotomy the anesthe-

siologist needs to administer 0.4 g /kg of manni-
tol. The patient is hyperventilated till the end tidal
carbon dioxide of 30 is reached.
The craniotomy is centered on the root of zygo-
ma.

Image showing the incision commonly used

The temporoparietal facial layer is attached to the

scalp during skin flap elevation. A large piece of
temporalis fascia is harvested prior to elevation of
the muscle flap, leaving behind a cuff of fascia on
either side of the muscle flap. This tissue will be of
immense help during wound closure.

Image showing craniotomy site marked

Image showing flap being elevated exposing tem-

poralis fascia

Surgical techniques in Otolaryngology

128
 dura is elevated along the floor
of middle cranial fossa from posterior to anterior
so that the greater superficial nerve is protected.
During this stage the arcuate eminence, greater
superficial petrosal nerve and petrous ridge are
identified.

Image showing bone flap being elevated

Bone flap of 4.5 X 4.5 cm is marked and 4 mm

cutting burr is used to remove majority of the
bone. A 4 mm diamond burr is used to remove
the final layer of bone over the dura.
Branches of middle meningeal artery will be Cottonoids are placed anteriorly and posteriorly
encountered, and the same needs to be controlled during dural elevation. Brisk bleeding from the
using cautery or bone wax. The bone flap is ele- middle meningeal artery at the level of foramen
vated off the dura with the use of Joker elevator. spinosum may be encountered. This can be con-
The bone flap should be kept moist by placing a trolled by the use of bone wax or oxycel packing.
wet gauze over it. Now is the time to check the
exposure. If the bone window is not flush with the House urban retractor is placed under the lip of
tegmen, then the excess bone is removed using a petrous ridge at the anticipated location of the
drill. internal acoustic meatus.

Elevation of Dura:

Dura is circumferentially elevated from the over-

lying cranium. Bipolar cautery is liberally used
during this procedure to stop bleeding from the
dura. Oxygel cigars are placed under the bone
flap anteriorly, posteriorly and superiorly. Ideally

Prof Dr Balasubramanian Thiagarajan

 Drilling is begun using a 4-0 diamond burr over
the arcuate eminence. The superior semicircular
canal will lie perpendicular to the petrous ridge.
The superior canal is blue lined. The internal
auditory canal would be located at 60° anterior
to the blue lined superior semicircular canal. The
meatal plane over the internal auditory canal is
lowered down to the level of posterior fossa dura.
The superior semicircular canal forms the poste-
rior limit of dissection.

Image showing arcuate eminence The bone over the internal acoustic meatus is
drilled till it becomes paper thin. The thinned
Identification of arcuate eminence is vital as it out bone can be removed using a 90° pick. The
indicates the approximate level of the superior skeletonization of internal auditory canal should
semicircular canal which invariably lies under- be continued up to the level of Bill’s bar. The lab-
neath. Greater superficial petrosal nerve should yrinthine segment of the facial nerve is identified
also be identified before proceeding any further. at the transverse crest. The cochlea lies deeper
The internal acoustic meatus is known to bisect than the plane of the labyrinthine segment of the
the angle formed by these two landmarks. facial nerve. If the surgeon does not drill deep to
the facial nerve anteriorly then cochlea will not be
violated. Auditory brain stem potentials should
be continuously monitored by an audiologist at
this stage.

Image showing the location of the internal audi-

tory meatus

Image showing dura over the internal auditory

canal excised

Surgical techniques in Otolaryngology

130
Dura over the internal auditory canal over the Closure of craniotomy:
superior vestibular nerve is excised exposing the
contents. A direct auditory nerve electrode is The House urban retractor is removed to allow
placed between the dura of the internal acoustic the temporal lobe to re expand. Bone flap is re-
meatus and the cochlear nerve for monitoring the placed and secured. Wound is closed in layers.
cochlear action potential in real time.

The separation between the facial nerve and

superior vestibular nerve is identified at the level
of transverse crest. The facial nerve is separated
from the superior and inferior vestibular nerves
at this location.

Tumor occupying the internal acoustic meatus

can be addressed. In case of larger tumors then
it is necessary to debulk the tumor before estab-
lishing a plane between the facial nerve and the
tumor. If real time monitoring of ABR reveals
increased latency or reduction in the amplitude of
the recorded waves, the act of tumor dissection is
paused for several minutes.

Closure:

Before closure hemostasis should be ensured at

the internal auditory canal and cerebello pontine Image showing a Diagrammatic representation
angle. Facial nerve should be documented by of structures visualized during middle cranial
stimulation. ABR should reveal that hearing is fossa approach
intact after the surgery.
Now is the time to repair temporal bone defect. Complications:
Bone wax is applied to all open air cells. A large
temporalis muscle plug or abdominal fat is used General:
to close the temporal bone defect.
1. Facial nerve palsy
The inner table of the bone flap is placed over 2. Vestibulocochlear nerve damage
the defect to prevent temporal lobe herniation 3. CSF leak
into the middle ear cavity. Tissue glue is used to 4. Intracranial extradural / intradural bleeding
further strengthen the seal. 5. Meningitis

Prof Dr Balasubramanian Thiagarajan

 Rhinology

History

Etymologically the term “sinus” represents the

geographic term indicating a gulf, a creek or
bay. As per the sources of Ancient Egypt dated
between 3700 and 1500 BC it was revealed that
the anatomy of nose and paranasal sinuses was a
common knowledge. In fact during mummifica-
tion rituals where the brain needs to be removed,
it was performed via the nostrils, presumably by
passing via the ethmoidal air cells.

In Hippocratic Corpus (460-377 BC) indications

for rhinosinusitis and polypi were found. Aulus
Cornelius Celsus (14 BC) extensively describes
paranasal sinuses anatomy. During the 16th
century, Sansovino defined the paranasal sinuses
as “cloaca cerebri” meaning the cavities responsi-
ble for the drainage of corrupted spirits from the
head. Leonardo da Vinci recognized the rela-
tionship between maxillary sinus and the teeth as Image showing Leonardo da Vinci’s sketch of
documented by his drawings. The first clear idea human skull
of this was given by the anatomist Berengario da
Carpi. A popular story those days is worth a mention
here. A patient who underwent extraction of
Andrea Vesalio composed De Humani Corporis upper canine tooth found that a continuous
Fabrica in 1543. It is the most important medical outflow of pus was coming out of the wound site.
document of those times. In this document he When he attempted to probe the cavity with a
accurately described the maxillary, frontal and feather, he realized that it penetrated for a long
sphenoid sinuses. He also claimed that these distance. He consulted Highmore who convinced
spaces were filled with air. Giulio Cesare Casseri the patient explaining the nature of the maxil-
gave his name to the maxillary sinus (antrum lary sinus. Gradual improvement of anatomical
Casserii). The name closely associated with the knowledge over the centuries was fundamental
maxillary sinus is that of Nathalien Highmore for the evolution of surgical techniques. In 1743,
(antrum of Highmore). Montpellier Louis Larmorier gained access to the
maxillary sinus through the oral cavity. This ap-
proach was documented and published in 1768.
Dentist Anselme L.B.B. jourdain treated a maxil-
lary suppurative sinusitis with irrigations via the
natural ostium. This procedure was commonly
performed between 1760 and 1765 and didn’t

Surgical techniques in Otolaryngology

132
meet with the expected success. mm wide close to the floor of the nasal cavity.
One year later Berlin Hermann Krause modified
The very first officially recognized reference text this technique by adding a drainage tube. Three
that described normal anatomy of nasal cavities years later, Ernst G.F. Kuster proposed the valid-
and paranasal sinuses was “Normal and Patholog- ity of the sublabial approach via the canine fossa
ic anatomy of nose and its accessory pneumatic creating an opening not bigger than a little finger
cavities” published by Emil Zuckerkandl in 1882. on which he placed a rubber plug, which can be
In this treatise the nose was considered insepara- removed if need to facilitate drainage of maxillary
ble from the surrounding structures. This book antrum.
was the source of inspiration for all rhinologists
of those times. Markus Hajek after a few years In 1893 George Walter Caldwell popularized
following publication of this book published a Lemorier’s technique suggesting the possibility
book titled “Pathology and therapy of inflam- of creating a “window” in the lateral wall of the
matory diseases of the nose and nasal passages”. inferior meatus via the canine fossa. This ap-
Another book authored by Grunwald explained proach was performed for the first time in Europe
how acute and chronic inflammations were the in 1896 in Breslau by Georg Boenninghaus. He
cause for sinusitis. This book was titled as “Book slightly modified this technique placing a mucous
on the nasal suppuration”. flap on the created fenestration. An identical
procedure was described by Robert H S Spicer
Origins of Paranasal sinus surgery and Henry Paul Luc in London and Paris. An-
other modification which was proposed is the
In the 1st century in Pompei, speculum shaped counter opening of the maxillary sinus through
nasal dilators were used for the visualization of the inferior meatus. Howard Lothrop published
the nasal cavities. For a long time the role of in 1897, the importance of a big fenestration in
interventional treatment remained limited com- the inferior meatus.
pared to the diagnostic options due to the pecu-
liar conformation of this anatomical area which Raymond Charles Claoue adopted intranasal
comprises of slits, recesses, reduced volumes antrostomy as a treatment for chronic maxillary
and narrow passes restricted by bony walls. The sinus infections. He also published his experi-
chance of surgical drainage of paranasal sinuses, ence in 1912. All these conservative treatments
in particular of the maxillary sinus was consid- were set aside after the introduction of innovative
ered only from the 17th-18th century. radical interventions in 1900. During this time
Gustav Killian described the resection of the un-
Towards the end of the 19th century, several cinate process with the enlargement of the nearby
authors started to perform puncture of the maxil- ostium. Halle was the first author to claim a large
lary sinus. Johann von Mikulicz-Radecki suggest- personal experience on intranasal ethmoidectomy
ed that antrum could be accessed via the middle and frontal and sphenoidal sinusotomies.
meatus. He was the first surgeon to introduce in
1886 the concept of antrostomy for the drainage In 1909, Dahmer performed an inferior antros-
of maxillary antrum. He recommended creation tomy cutting the anterior part of the inferior
of an opening measuring 20 mm long and 5-10 turbinate. This opening was so wide, that the

Prof Dr Balasubramanian Thiagarajan

patient could self irrigate their maxillary antrum
following this procedure. It was common knowl- In early 1920’s Harris Peyton Mosher of Harvard
edge that antrostomy carried out via the inferior University studied in depth the paranasal sinus-
meatus could become stenosed and hence a large es anatomy by performing meticulous cadaver
opening needs to be created to overcome this dissection. His interest was inspired by the an-
problem. atomical atlas published in 1920 in Philadelphia
by Schaeffer titled: “The nose, paranasal sinuses,
The first frontal sinus surgical procedure was de- nasolacrimal passageways and olfactory organ in
scribed in 1750. Despite more than two centuries man”.
since the description of the first procedure on the
frontal sinus, the optimal procedure still remains The first approaches to frontal sinus was first
unclear. Even though frontal sinus surgery makes evolved by ophthalmic surgeons. Alexander Og-
up only a small portion of all paranasal sinus sur- sten managed to reach the frontal sinus through a
gery, the literature is filled with publications on horizontal incision performed under the eyebrow,
the subject. In 1954 Ellis surmised that chronic drilling the bone and creating a breach sufficient-
frontal sinusitis is difficult to treat and the treat- ly wide to allow the opening of both frontal si-
ment modality could often be unsatisfactory and nuses. Afterwards, he modified this procedure by
sometimes disastrous. executing the incision more medially, at the root
of the nose. This technique was later described
The ideal treatment for diseases involving frontal in 1894 by Luc, who used it for the insertion of a
sinus is one that will provide complete relief of drainage tube in to the frontal sinus. This process
symptoms, eradicate the underlying disease pro- caused skin to grow inside the hole, causing terri-
cess, preserve the function of the sinus, cause the ble malformations. In order to avoid these com-
least morbidity and cosmetic deformity. Over the plications, Killian in 1900 performed an incision
last two centuries a variety of surgical procedures through the eyebrow preserving the supraorbital
have been described for managing frontal sinus region, so he obtained a complete exposure of the
disease. frontal sinus and reached the ethmoidal cells after
prolonging downward the previous incision.
Gerber and Kubo preferred middle meatal an-
trostomy which was performed using a perforator Zuckerkandl focused his studies on the sphe-
designed by Onodi in 1902. noid sinus. He also stated that it was possible to
reach the sphenoid sinus via the nasal cavities.
Sluder practiced complete removal of entire me- He drained the sphenoid sinus via this passage.
dial wall, preserving only the inferior turbinate. These studies formed the basis for transnasal
On the contrary, in 1910 Rethi recommended the sphenoidal approach for removing pituitiary
amputation of only the anterior two thirds of the lesions.
inferior turbinate. Lavelle and Harrison found a
higher rate of healing and a lower frequency of Recent advances that has taken place in the
complications in case of chronic sinusitis treated field of imaging and endoscopic surgical tech-
with an antrostomy performed via the middle niques have lead to a resurgence of intra-nasal
meatus. procedures for the management of frontal sinus

Surgical techniques in Otolaryngology

134
disease, particularly chronic frontal sinusitis disease. The mucosa was stripped to the level of
which could be a highly morbid / sometimes life frontal recess, and a stent was placed for tem-
threatening condition due to its potential compli- porary drainage. In 1898 Riedel described the
cations. Despite these advancements, orbital and first procedure for obliteration of frontal sinus.
intracranial complications following frontal sinus He advocated complete removal of the anterior
infections continue to occur. table as well as the floor of the frontal sinus with
stripping off the mucosa. This procedure had the
History of frontal sinus surgery can be conve- advantage of removing osteomyelitic bone as well
niently divided into three eras for better under- as allowing for easy detection of recurrent dis-
standing: ease. This procedure caused unsightly cosmetic
forehead deformity. Killian in 1903 described a
Era of Trephination (1750) modification of the Riedel-Schenke procedure.
This modification involved preservation of one
Era of radical ablation procedures (1895) centimeter bar of the supraorbital rim. He also
recommended an ethmoidectomy y with rota-
Era of conservative procedures (1905) tion of mucosal flap into the frontal sinus with
stenting to prevent stenosis. Killian’s procedure
was abandoned because of the high incidence of
Era of Trephination: late morbidity with restenosis, supraorbital rim
necrosis, postoperative meningitis and mucocele
Frontal sinus surgery was first described in the formation as well as death.
18th century. It was documented that as early as
1750, Runge performed an obliteration procedure Era of conservative procedure:
of the frontal sinus. The first report to be pub-
lished was in 1870 by Wells describing an external Because of the risk of significant cosmetic defor-
and intracranial drainage procedure for a frontal mity as well as the high failure rate of those abla-
sinus mucocele. tive external procedures, an era of conservatism
followed as a natural corollary. This era was char-
In 1884 Alexander Ogston described a trephi- acterised by intranasal approaches to frontal sinus
nation procedure through the anterior table to as well as external frontoethmoid techniques.
evaluate the frontal sinus. He also dilated the In 1908, Knapp described an ethmoidectomy
naso-frontal duct, curetted the mucosa and estab- through the medial wall and entering the frontal
lished drainage with a tube that was inserted into sinus through its floor, by which he removed dis-
the duct. This tube kept the duct patent. eased mucosa and enlarged the naso frontal duct.
This operation did not receive widespread recog-
Era of Radical Ablation Procedure: nition. In 1911, Schaeffer proposed an intranasal
puncture technique to re-establish the drainage
At the turn of the century a number of physicians and ventilation of the frontal sinus. Numerous
were advocating a radial frontal sinus procedure. complications were encountered which included
Kuhnt in 1895 described removing the anterior intracranial penetration. Between 1901 and 1908,
wall of the frontal sinus in an attempt to clear the Ingals, Halle, Good, and Wells described several

Prof Dr Balasubramanian Thiagarajan

intranasal procedures in which the frontal process inferior meatus was Spielberg in 1922. He called
of maxilla was chiseled out, and a burr was used this procedure antroscopy. In 1981, Buiter e
to remove the floor of the frontal sinus. Straatman developed a surgical endoscopy assist-
ed method for the fenestration of posterior fon-
In 1914, Lothrop described a procedure to en- tanelle and in the next year Draf used the micro-
large the frontal drainage pathway in a way that scope matched with an angled optics endoscope.
would prevent restenosis as well as closure. The Heerman described an intranasal operation con-
procedure described a combined intranasal eth- ducted with a binocular microscope, specifically
moidectomy and an external ethmoid approach designed for more precise cleaning of the middle
to create a common frontal nasal communication and posterior ethmoid cells and sphenoid sinus.
by resecting the frontal sinus floor, the frontal
sinus septum and the superior nasal septum. Lo- Evolution of endoscopy led to the development
throp admitted that lack of visualization during of increasingly advanced tools to facilitate en-
the intranasal approach made the procedure more doscope assisted intranasal surgical procedures.
dangerous. Resection of the medial orbital wall The rigid nasal endoscope of Hopkins allowed
allowed collapse of orbital soft tissue into the eth- the surgeon to explore the interior of the nose in
moid area, with subsequent stenosis of the frontal detail. Adoption of rigid angled optics provided
drainage pathway. benefits for the display of the sinuses. Another
technical progress was represented by the intro-
History of endoscopic sinus surgery duction of an endoscope equipped with irriga-
tor-aspirator and angled optics, rotatable and
Bozzini described a simple appliance and its use interchangeable. Modern conception of function-
for lighting the internal cavities and the spaces of al endoscopic sinus surgery is attributed to Walter
the living animal’s body. He used his knowledge Messerklinger. He first published his article on
of physics to create a Lichtleiter (light conduc- the subject in 1967, stating that the anterior eth-
tor), which allowed him to explore the external moidal cells were the keystone of sinusitis. Mes-
auditory canal, the nasal cavities and oropharynx. serklinger and Stammberger developed a step-by-
Since this discovery, several versions of endo- step intervention of the lateral wall of the nose.
scopes have followed with different equipment.
At first, the endoscopes were specifically used for
diagnostic procedures, including the sampling of
histological specimen.

In 1903, Hirschmann published a study of five

ethmoids in which the middle turbinate was more
or less extensively removed. He was the first to
use a real endoscope for the examination of nasal
cavities and paranasal sinuses. Hirschmann and
Reichert introduced the endoscope in clinical
practice. The first surgeon who performed an
endoscopic probing of the maxillary sinus via

Surgical techniques in Otolaryngology

136
Prof Dr Balasubramanian Thiagarajan
Antral Puncture and Lavage
Anatomy of inferior meatus:
Introduction:
Inferior meatus is the largest of the three meatus-
Focus on maxillary sinus cavity pathology dates es of the nasal cavity. This is actually the space
back to the 17th century. Treatment for suppura- between the inferior turbinate and the lateral
tion of maxillary sinus was common during that nasal wall. It extends almost the entire length of
period. One of the earliest descriptions of intra- the lateral wall of the nose. It is broader in front
nasal antrostomy as an approach to maxillary than behind which makes it easy
sinus was dated back to 1770 by Gooch. Routine for accessing the lateral nasal wall from here. An-
puncture of maxillary sinus via the inferior me- teriorly the nasolacrimal duct opens here.
atus was performed during 1880’s following the
classic publication of Lichwitz who designed the Inferior turbinate is a separate bone unlike the
classic trocar and cannula that can be used for superior and middle turbinates which are compo-
performing the procedure. nents of ethmoid bone. Inferior concha / inferior
turbinate matures via endochondral ossification.
Krause in 1887, Mickulicz in 1887 standard-
ized the procedure. Mickulicz understood the Articulations of inferior turbinate:
anatomical and physiological pitfalls of inferior
meatal antrostomy which included its propensity Anterior – Frontal process of maxilla
for spontaneous closure making it a temporary Anteromedial – Articulates with the uncinate
procedure. This was hence gradually replaced by process of ethmoid bone and lacrimal bone
canine fossa antrostomy (Caldwell Luc proce- Posteromedial – Perpendicular plate of palatine
dure) by 1897. bone

Acute maxillary sinusitis was common problem Indications for antral lavage:
during the 17th and 18th centuries. Radiological
investigations were not commonly available hence 1. Acute bacterial maxillary sinusitis causing pres-
antral lavage was used as a sure symptoms in middle of face
diagnostic as well as a therapeutic procedure for 2. Feeling of numbness of teeth / symptoms that
diagnosing and treating acute maxillary sinusitis. does not resolve with medical management
Antral puncture and aspiration remained gold 3. Patients with maxillary sinusitis who are not
standard for diagnosing acute maxillary sinusitis fit for general anesthesia to perform functional
for a long time. endoscopic sinus surgery
With the advent of functional endoscopic sinus 4. Patients on assisted mechanical ventilation
surgery antral lavage has fallen out of fashion. But who commonly develop sinusitis (nearly 40% of
it should be stated that it remains still the most them develop). Lavage in these patients can be
cost-effective procedure in diagnosing and man- performed as a bedside procedure under local
aging maxillary sinus infections. anesthesia to clear the pent-up secretions from
the maxillary sinuses.

Surgical techniques in Otolaryngology

138
5. In patients with permanent disability of muco- sia. Topical anesthesia is produced by using 4%
ciliary clearance mechanism like kartagener’s syn- xylocaine soaked nasal pledgets. Topical anes-
drome and Young’s syndrome. In these patients thesia lasts about 45 minutes which is more than
FESS is almost useless and only inferior meatal sufficient for completion of the procedure. While
antrostomy could salvage them. using 4% xylocaine topical anesthesia it should be
ensured that the maximum volume of drug used
Contraindications: should not exceed 7ml. A reasonable dose of xy-
locaine that is safe for topical use is 4mg/kg body
1. In young children in whom maxillary sinus is weight. By mixing xylocaine with adrenaline,
not fully developed. Maxillary sinus completes its the effect of the drug can be prolonged plus the
development only after the age of 9. added benefit of vasoconstriction which reduces
2. Blow out fracture of orbit / history of blow out bleeding. Ideal is to mix I ampule of adrenaline to
fracture of orbit because irrigated fluid from the one 30 ml bottle of 4% xylocaine. This will ensure
sinus could infuse into the orbit via the fracture that adrenaline concentration is about 1 in 10000
line causing orbital problems units. Cottonoids if available are preferred to
3. Patients who have undergone previous surger- pledgets.
ies involving the lateral nasal wall as the needle
could enter through the posterior wall of maxil- Each nasal cavity should be packed with 3 packs
lary sinus into the pterygopalatine fossa soaked with 4% xylocaine with 1in 10000 units
4. In patients with atrophic rhinitis because the adrenaline. Before packing the pack should be
lateral nasal wall will be pretty thick in these squeezed to remove excess xylocaine. The first
patients making the procedure rather difficult. It pack is placed over the floor of the nasal cavity,
may require a chisel and gouge to create inferior the second one is placed in the inferior meatus.
meatal opening in these patients. Simple trocar The third pack is placed in the middle meatus
and cannula would not do. area. Surgeon should be aware that the posterior
pharyngeal wall mucosa would also be anesthe-
Procedure: tized by xylocaine trickling into that area. This
could cause the patient to aspirate because the
This procedure involves introduction of a cannu- sensation is lost. The surgeon should be conscious
la into the maxillary sinus cavity via an opening about this problem while performing the proce-
made in the inferior meatus. This procedure is dure. The patient should be instructed not to sniff
rather outdated these days because the maxillary while nasal packing is done as it would promote
sinus drainage in the presence of normal muco drug to trickle into the posterior pharyngeal wall.
ciliary clearance mechanism is not dependent on
gravity. The beating cilia always propels the se- A short description of innervation of nose and
cretions from the sinus cavity towards the natural nasal cavity would not be out of place. Nasal
ostium which is situated slightly above. There is innervation can be simplified by dividing it into
no point in expecting gravity to work against the internal (mucosal) innervation and external (in-
natural muco ciliary clearance mechanism. nervation involving the skin of the nose).

This surgery is performed under local anesthe-

Prof Dr Balasubramanian Thiagarajan

Innervation of external nose: turbinate and this innervates the posterior nasal
cavity. It is this ganglion that is blocked by the
The external nose is innervated by the ophthal- pledget placed in the middle meatus of the nose.
mic division of 5th cranial nerve, and maxillary The anterior and posterior ethmoidal nerves and
division of 5th cranial nerve. The superior aspect the sphenopalatine ganglion through the naso-
of the nose including the tip is supplied by In- palatine nerve provides sensation to most of the
fratrochlear nerve. The supratrochlear nerve and nasal septum. The cribriform plate holds the spe-
external nasal branch of anterior cial sensory branches of the olfactory nerve thus
ethmoidal nerves also supply this area. The infra catering to the sensation of smell.
orbital nerve supplies the inferior and lateral
aspects of the nose extending up to the lower The nerves that are blocked during antral wash
eyelids. are:

1. Superior alveolar nerve near the inferior me-

atus
2. Anterior ethmoidal nerve near the roof of nasal
cavity
3. Posteriorly the sphenopalatine ganglion

Image showing innervation of external nose

Sensory innervation of nasal mucosa:

The interior of nasal cavity is subdivided into the Image showing the theory behind antral wash
nasal septum, lateral nasal walls and the cribri-
form plate. The superior inner aspect of lateral
nasal wall is supplied by the anterior and posteri-
or ethmoidal nerves. The sphenopalatine gangli-
on is located in the posterior end of the middle

Surgical techniques in Otolaryngology

140
The patient is comfortably seated in a chair with
adequate back support. Eye pad should be used
to blind the patient. This will reduce the anxiety
level of the patient.

The Tilley Lichwitz trocar and cannula is passed

under the attachment of inferior turbinate and is
directed towards the outer canthus of the ipsi-
lateral eye. With a firm turn the inferior meatus
is punctured. While introducing index finger of
the surgeon should be placed at the junction of
anterior 1/3 and posterior 2/3 of the trocar can-
nula assembly. This will help in ensuring the safe
penetration depth. The trocar is gently removed
leaving the cannula in position. A syringe is con-
nected to the cannula and aspiration is attempted. Image showing Lichwitz trocar and cannula
If it is inside the maxillary sinus secretions could
be aspirated. If the sinus is empty then air will
be aspirated. If gross blood is aspirated then it
should be construed that the cannula is not inside
the maxillary sinus cavity. A Higginson’s syringe
which contains a bulb and a one-way valve is
connected to the cannula and the other end of the
syringe is placed inside a vessel containing water
at body temperature. Flushing can be performed
by squeezing the bulb of Higginson syringe.
Dilute potassium permanganate wash can also
given. Three successive washes should be given.
A kidney tray should be held under the patient’s
mouth. The patient can be asked to hold the tray
so that their mind will be diverted from the actual
procedure. When the antrum is being flushed the
patient should be asked to keep the mouth open
so that fluid used for irrigation will drain through
the patient’s mouth. Image showing the course of trocar and cannula

Prof Dr Balasubramanian Thiagarajan

Image showing the nasal opening of nasolacri-
mal duct in the inferior meatus. Injury to this
structure should be avoided at all costs during Image showing the fluid used for antral wash
the procedure. draining through the antrostomy

Complications:

1. Bleeding
2. Orbital damage. Perforation of orbital floor will
cause proptosis and pain
3. Cheek swelling: This is caused by breaching the
soft tissue of the cheek and the anterior wall of
the sinus.
4. Air embolism due to injury to veins
5. Infection of maxillary sinus
6. Vaso vagal shock

Image showing pus draining out of inferior me-

atal antrostomy opening

Surgical techniques in Otolaryngology

142
Maxillectomy
Indications for maxillectomy:
Introduction:
1. Malignant tumors involving maxilla / lateral
The concept of maxillectomy was first described nasal wall
by Lazars in 1826. After this description it took 2. Fungal infections causing extensive destruction
nearly three years for Syme to perform the first of sinuses
maxillectomy (1829). Earlier attempts at this sur- 3. Chronic granulomatous diseases involving nose
gery failed because of excessive bleeding. Bleed- and sinuses
ing and infection were two scrooges which 4. As a part of combined excision of skull base
caused unacceptable morbidity and mortality in neoplasm
patients following maxillectomy. In 1927 Port-
mann & Retrouvey suggested sublabial transoral Partial maxillectomy procedures are indicated in
approach to remove maxilla. This approach patients with:
obviated the use of disfiguring facial incisions.
Rapid advances which took place in the field of 1. Slow growing tumors involving nose and sinus-
anesthesia and surgical techniques in 1950 rekin- es (inverted papilloma)
dled the interest in total maxillectomy as a viable 2. Tumors localized to inferior wall of maxilla
treatment option for malignant lesions involving
maxilla. It was during this period that Weber Important considerations before deciding on
Ferguson came out with his epoch making lat- surgery:
eral rhinotomy incision which caused very little
cosmetic deformity. Later various modifications 1. Extent of the lesion
of these incisions were used to perform maxillec- 2. Histopathology of the lesion
tomy. 3. Involvement of adjacent areas
4. Precise location of the bulk of the mass
In 1954 Smith did what was considered impos-
sible. He combined total maxillectomy with Role of Nasal endoscopy and clinical examina-
orbital exenteration. It was only after Smith’s tion:
demonstration of extended total maxillectomy
curative surgery for maxillary carcinomas began This is really vital in deciding not only the extent
to take center stage. Fairbanks & Barbosa (1961) of the disease but also in determining the optimal
described infratemporal fossa approach to resect treatment modality. It also helps in discussing
advanced malignancies of maxilla. These tumors prognostic issues with the patient and their near
were considered to be inoperable till then. ones.

In 1977 Sessions & Larson first envisaged medial It helps in examination of the nasal cavity and
maxillectomy and were also responsible for coin- also provides the first look at the disease process
ing the term. With the advent of nasal endoscope from which biopsy can be done. Spread of lesion
resection of tumors involving lateral nasal wall outside the confines of maxilla by eroding the
under endoscopic vision is the order of the day. antero lateral wall can be ascertained by careful

Prof Dr Balasubramanian Thiagarajan

palpation of the anterior wall and in assessing the
integrity of the function of the inferior orbital
nerve. Erosion of the posterior wall of maxilla
with extension of lesion to pterygopalatine fossa
can be ruled out clinically by absence of trismus.

Histopathological diagnosis is a must before

deciding on the optimal management modality. If
tumor histology is suggestive of lymphoreticular
tumors / rapidly proliferating embryonal tumor
like rhabdomyosarcoma then irradiation is the Image showing Coronal and Axial CT show-
preferred treatment modality. ing Growth involving right maxilla eroding its
medial, inferior and antero lateral walls. Axial
Role of imaging: CT shows the same mass eroding posterior wall
of maxilla extending on to pterygopalatine fossa.
1. Both axial and coronal CT will have to be Pterygoid process is not visible on right side ?
performed in order to ascertain the extent of the eroded.
lesion.
2. Imaging also helps in deciding the optimal
osteotomy location during surgery. The level of
frontoethmoidal suture line should be identified
well in advance. Superior osteotomy above this
level will cause intracranial injury and CSF leak.
3. MRI is indicated in patients who have skull
base erosion in order to identify intracranial
extension.

Role of prosthodontist:

Preoperatively prosthodontist should examine the

patient and design an optimal prosthesis which is
actually a temporary one. This can be fixed imme-
diately after surgery. Final prosthesis can be fitted
after the completion of treatment which includes
irradiation / chemotherapy. Image showing Coronal CT nose and sinuses
showing soft tissue shadow involving inferior
portion of maxilla with erosion of the floor of
maxilla

Surgical techniques in Otolaryngology

144
Role of ophthalmologist: Ryles tube insertion:

Ophthalmic examination helps in ruling out oc- This is ideally performed before anesthetizing the
ular involvement. If orbit is involved then max- patient. Ryles tube in position will help in feeding
illectomy will have to be combined with orbital the patient during the initial post-operative peri-
exenteration. od. Even though it is not a must if inserted serves
a good purpose.
Procedure:
Hypotensive anesthesia can be administered if
This surgery is ideally performed under general there is no contraindication as it would help in
anesthesia. Administration of pre-operative anti- minimizing blood loss during the procedure. If
biotics has been considered to reduce incidence endotracheal intubation is preferred to tracheos-
of post op infections. Ideally it should be a broad tomy then oral intubation is ideal. The endotra-
spectrum antibiotic which could cover the nor- cheal tube should be secured to the side opposite
mal flora of nasal and oral cavities. to that of the tumor. It is anchored to the lower lip
without distorting the upper lip.
The question whether tracheostomy should be
performed or not is determined by the extent of Position:
lesion and the amount of palate that needs to be
removed. If large amount of palatal tissue needs Patient is put in supine position with head turned
to be removed to give adequate tumor margins 180° from the anesthetist.
then it is safer to resort to preliminary tracheos-
tomy. Incision:

Advantages of preliminary tracheostomy include: Even though various incisions are available au-
thor prefers to use Weber Ferguson incision and
1. Anesthesia can be administered through it its various modifications. Modifications of Weber
2. Provides unhindered view of oral cavity which Ferguson incision is necessary if other areas like
is helpful during oral phases of surgery orbit needs to be attended. Lateral canthotomy
3. It helps to secure airway during post op period can be combined with Weber Ferguson incision
even in the presence of intra oral edema. to expose orbital boundaries and malar area. Lip
splitting incision a modification of Weber Fergu-
Tarsorraphy is performed on the side of lesion. son incision is preferred if infratemporal fossa is
This helps in protecting eye and cornea from involved.
injury. Lateral tarsorraphy alone could suffice if it
could provide adequate eye closure. Ideally silk is
used to perform this procedure. Before perform-
ing tarsorraphy it would be prudent on the part
of the surgeon to apply eye ointment in order to
prevent excessive drying of cornea.

Prof Dr Balasubramanian Thiagarajan

 the midline.
3. Infraorbital component of the incision passes
about a couple of millimeters from the lower eye
lid margin till the malar eminence is reached.

Whatever may be the type of incision used

the skin is slit right through till periosteum is
reached. This enables cheek flap to be elevated
from the antero lateral surface of maxilla in the
subperiosteal plane. If the anterior wall of maxilla
is eroded by the mass with skin involvement then
dissection is slightly altered so that the involved
skin overlying the anterolateral wall of maxilla is
also removed en-bloc along with the tumor.

Probable bleeding sites encountered during this

incision:
1. Angular vein close to the inner canthus of eye.
If not ligated properly may cause irksome ooze
during surgery.
2. When lip is being split right in the middle labi-
al vessels may lead (superior labial artery)
Image showing the Weber Ferguson Lip splitting 3. Infra orbital vessels when infraorbital limb of
incision used in maxillectomy. the incision is being made.

Infraorbital nerve is sacrificed after taking a biop-

Weber Ferguson incision: sy from it to rule out perineural invasion. This is
mandatory in all patients with adenocarcinoma
Before actually beginning the process of incision of maxilla. Adenocarcinoma has a propensity to
the area should be marked and infiltrated with 1% spread via nerve sheaths.
xylocaine with 1 in 100,000 units adrenaline. This
infiltration if done properly will help in minimiz- After elevating the cheek flap, the inferior and
ing intraoperative bleeding during surgery. medial periorbita are elevated exposing the fol-
lowing areas:
The modified Weber Ferguson incision used in
total maxillectomy has three components. 1. Floor of orbit
1. Curving incision from the medial canthus to 2. Lacrimal fossa
the ala of the nose at the nasolabial sulcus. 3. Lamina papyracea
2. This incision is rounded inferiorly along the
upper border of upper lip till the center of the lip
is reached. The upper lip is ideally split right in

Surgical techniques in Otolaryngology

146
Image showing the infraorbital limb of the inci-
sion Image showing incision is ideally deepened up
to the subperiosteal plane by using diathermy
cautery. Use of cautery minimizes bleeding to a
great extent.

Identification of lacrimal sac and duct: This is a critical step during the procedure as
it gives excellent opportunity to the surgeon
The lacrimal sac is identified, dissected and re- to identify orbital involvement. If periorbita is
tracted. This maneuver stretches and exposes the breached by the tumor then it calls for histolog-
lacrimal duct. The nasolacrimal duct is usually ical confirmation of orbital involvement. Frozen
transected at its junction with the sac. The sac is section will of used during this stage of the proce-
marsupialized. This is performed by dividing the dure.
sac and suturing the edges to the periorbita.

Prof Dr Balasubramanian Thiagarajan

 the frontoethmoidal suture line. Above this line
dura is present. In tumors involving roof of the
ethmoid (Fovea) require skull base resection in
order to provide adequate tumor margins. If
fovea is not involved by the disease then ethmoid
bone is removed along the frontoethmoidal su-
ture line to provide adequate exposure.

Tip:

While performing the su-

perior cuts please ensure
that it is done in a direc-
tion parallel to the nasal
floor in order to avoid
inadvertent entry into
skull base.
Image showing transection at the level of malar
buttress using Gigli saw

Transection of infraorbital rim: Intraoral phase of surgery:

This is transected laterally at the malar buttress. Palatal incision

Gigli’s saw may be useful during this phase of
surgery. Incision is made over the hard palate from just
posterior to the lateral incisor till the junction
Tip: While using gigli saw during osteotomy pro- with that of the soft palate is reached. Incision is
cedures, saline should be dripped on the surgical deepened up to the level of periosteum. At the
field continuously to prevent tissue damage due junction of soft palate the incision curves hori-
to overheating which could occur during this zontally and extend up the maxillary tuberosity
procedure. where it is rounded.

The medial orbital rim is transected just below

Surgical techniques in Otolaryngology

148
 Tip:

Bleeding will be mini-

mized if this area is also
infiltrated with 1% xy-
locaine mixed with 1 in
100,000 units adrenaline.

Image showing osteotome being used for palatal

resection
Division of hard palate:
Osteotomies over lateral orbital wall and posteri-
This is usually done using an osteotome / recip- or floor of orbit are completed thereby allowing
rocating saw. Author prefers to use osteotome. down fracture of maxilla. The only attachment
Palatal division is started about 2-3 mm from the remaining at this state is the pterygoid plate.
ipsilateral nasal septum (if the tumor margin per- Attachment of maxilla to pterygoid palate can be
mits). This can be modified to suit tumor mar- removed using a curved osteotome.
gins. Lateral incisor if present and uninvolved Maxilla can now be freed by lateral rocking
can be preserved for prosthesis fitment purposes. movements. At this stage brisk bleeding may
The central incisor can be compromised. It is be encountered. This is usually due to internal
easy to use osteotome from the cavity of the cen- maxillary vessels and pterygoid plexus. Packing
tral incisor after removing it. the entire area using a hot pack will help in con-
trolling bleeding. Majority of this bleeding re-
After completing palatal osteotomy the soft tissue duces appreciably with hot packing. In the event
attachments between hard and soft palate are of hot packing failing to control bleeding then
freed using sharp dissection / unipolar diathermy individual vessels will have to be cauterized using
cautery. bipolar cautery.

Prof Dr Balasubramanian Thiagarajan

 After the entire maxilla is removed the area is
washed with saline and betadine solution. Tem-
porary prosthesis is inserted. Gutta percha is used
to fashion this prosthesis. It is always optimal to
have a prosthodontist to do this job.

Image showing disarticulation of maxilla by gen-

tle lateral rocking movements

Image showing Obturator in position

Image showing hot pack in position after remov-

ing the entire maxilla

Surgical techniques in Otolaryngology

150
 Image showing maxillectomy specimen

Bone cuts a pictorial review:

It will not be out of place to review the bone cuts

performed in total maxillectomy from osteology
point of view. Pictures below will give a clear cut
view of various osteotomies performed before
maxilla could be disarticulated.

Image showing wound closure

Prof Dr Balasubramanian Thiagarajan

 Image showing various bone cuts

Complications:

1. Intraoperative hemorrhage
2. Troublesome Epiphora
3. Damage to orbital structures
4. Damage to cornea
5. Visual disturbances
6. Loss of vision due to over packing the maxil-
lectomy cavity compromising vascularity of optic
nerve
7. Velopharyngeal incompetence (Nasal leak of
ingested fluids)
8. Cosmetic defects / scars
9. Trismus due to scarring of muscles of mastica-
tion

Surgical techniques in Otolaryngology

152
Prof Dr Balasubramanian Thiagarajan
SUBMUCOSAL RESECTION OF NA- United States. Using a special saw, the deviated
SAL SEPTUM & SEPTOPLASTY portion of the nasal septum was removed along
with its corresponding mucosa. The results of this
procedure were therefore suboptimal.
Introduction:
Ingals (1882) was the first to introduce en-bloc
Nasal obstruction is a common complaint that
resection of small sections of septal cartilage.
brings the patient to a doctor. If it is caused by
Because of this innovation he is considered to be
deviated
the father of modern septal surgeries. During this
nasal septum then correction of this deviation be-
period cocaine was being widely used as topical
comes mandatory. A successful septal correction
anesthetic for surgical procedures.
surgical procedure really improves the quality of
life of the patient. Submucosal resection of na-
Ash (1899) was the first person to suggest that al-
sal septum and septoplasty are two commonly
tering the tensile curve of septal cartilage straight-
performed surgeries with an aim to correct the
ened it without resorting to actual resection.
septal deviation and improve nasal airway. The
type of surgery depends on the type of deviation.
Freer and Killain (1902 & 1904) described the
If the deviation of nasal septum is anterior to the
submucosal resection of nasal septum. This
Cottle’s line (a vertical imaginary line dropped
procedure served as the foundation of modern
between the nasal processes of frontal and maxil-
septoplasty techniques. They advocated raising
lary bones) septoplasty is preferred. If the devia-
mucoperichondrial flaps and resecting the car-
tion is posterior to this line submucosal resection
tilaginous and bony septum (which included
of nasal septum is preferred.
the vomer and perpendicular plate of ethmoid),
leaving 1 cm dorsally and 1 cm caudally to main-
History:
tain support.
First description of nasal surgery could be found
Metzenbaum and Peer (1929) were the first to
in the Ebers Papyrus (3500 B.C) written in Egyp-
manipulate the caudal septum using a variety
tian. The procedures described in this papyrus
of techniques. The classic SMR is ineffective /
was reconstructive in nature because rhinectomy
less effective in correcting this area of deviation.
was a frequent form of punishment those days.
Metzenbaum also in addition advocated the use
of swinging door technique.
Quelmatz (1757) was one of the earliest physi-
cians to address septal deformities. His famous
In 1937 Peer recommended removal of caudal
recommendation was the application of digital
portion of nasal septum, straightening it and then
pressure on the septum on a daily basis. He be-
replacing it in the midline position.
lieved this procedure could correct the deviation
and make the septum to become straight.
Cottle in 1947 introduced the hemitransfixation
incision and the practice of conservative septal
Adams (1875) recommended fracturing and split-
resections.
ting of nasal septum. Bosworth operation: This
was rather popular in late 19th century in the

Surgical techniques in Otolaryngology

154
 2. During an acute episode of rhinitis
Cottle’s types of septal deviations: 3. In the presence of bleeding diathesis
4. If the patient is having untreated DM & HT
Cottle has classified septal deviations into three
types: Anesthesia:
Simple deviations: Here there is mild deviation of
nasal septum, there is no nasal obstruction. This This surgery can be performed both under local
is the / General anesthesia. GA is used only in appre-
commonest condition encountered. It needs no hensive patients. The basic advantage of LA is that
treatment. there is minimal bleeding during the surgery and
Obstruction: There is more severe deviation of the entire surgery can be performed as a day care
the nasal septum, which may touch the lateral procedure.
wall of the nose, but on vasoconstriction the
turbinates shrink away from the septum. Hence Position:
surgery is not indicated even in these cases.
Impaction: There is marked angulation of the The patient is placed in a reclining position with
septum with a spur which lies in contact with head end of the table raised.
lateral nasal wall. The space is not increased even
on vasoconstriction. Surgery is indicated in these The nasal cavities are packed strips of roller gauze
patients. dipped in 4% xylocaine with 1 in 100,000 units
adrenaline. The gauze strips should be squeezed
Indications of SMR: to remove excess xylocaine before inserting into
the nasal cavities. This is done to minimize xy-
1. Deviated nasal septum causing symptoms of locaine absorption by the nasal cavity mucosa as
nasal obstruction and recurrent head aches this could cause systemic toxicity. On no account
2. Deviated nasal septum causing obstruction to the volume of 4% xylocaine used for topical an-
ventilation of paranasal sinuses and middle ear esthesia should exceed 7ml. One strip is placed in
causing recurrent sinusitis and ear infections the floor of the nose, the second one is placed to
3. Recurrent epistaxis from a septal spur occupy the middle portion of the nasal cavity. The
4. As a part of septorhinoplasty for cosmetic cor- third strip is placed superior to the second one.
rection of external nasal deformities Both nasal cavities should be packed. The author
5. As a preliminary step in trans-septal trans prefers to pack the nose even if the surgery is
sphenoidal hypophysectomy, vidian neurectomy performed under GA as it shrinks the turbinates
6. To obtain cartilage graft thereby creating more space for the surgeon.
7. For closure of septal perforations
Infiltration of nasal septum:
Contraindications:
It is done at the mucocutaenous junction on both
1. Patients below the age of 17 as it would impede sides with 2% xylocaine with 1 in 100,000 adren-
growth of middle third of face by interfering with aline.
growth centers. Successful infiltration not only produces anes-

Prof Dr Balasubramanian Thiagarajan

thesia in the area but also elevates the mucoperi-
chondrium as evidenced by blanching reaction
seen in the septal mucosa.
Killian’s incision is used. 15 blade knife is used
to cut the mucoperichondrium obliquely about 5
mm above the caudal border of the septal carti-
lage. Flaps are elevated on both sides of the nasal
septum exposing the bony and cartilaginous
portions of the nasal septum. The entire septum
including cartilage and bone is removed using a
combination of Ballanger’s swivel knife and Lucs
forceps.

Image showing mucoperichondrial flap elevated

on one side of the septum

Image showing incisions used in SMR & Septo-

plasty

The mucoperichondrial flap is sutured using 3-0

chromic catgut. The nose is packed gently with
ointment impregnated roller gauze or using a
Merocel nasal pack. Both nasal cavities should be
packed. Image showing mucoperichondrial flap elevat-
ed on the opposite side after incising the septal
cartilage

Surgical techniques in Otolaryngology

156
 Indications:
Complications of SMR:
1. Symptomatic deviated nasal septum
1. Bleeding 2. As part of rhinoplasty procedures
2. Septal hematoma - If the nasal cavity is prop- 3. To remove septal spur that cause epistaxis
erly packed then this will not be a problem. If he- Contraindications:
matoma is present then it should be evacuated by 1. Acute nasal or sinus infection
application of digital pressure and nasal cavities 2. Untreated DM and HT
should be repacked again. 3. Bleeding diathesis
3. Septal abscess - This usually follows septal
hematoma Anesthesia is as enumerated for SMR surgery.
4. Septal perforation - Occurs when the other side The septum is infiltrated with 2% xylocaine with
of the nasal septum is breached during elevation 1 in 100,000 adrenaline. Incision is usually giv-
of mucoperichondrial flap en on the concave side of nasal septum. Freer’s
5. Depression of Bridge of nose - This usually oc- hemitransfixation incision is preferred. This is
cur at the supratip area due to too much removal made at the lower border of the septal cartilage. A
of cartilage along the dorsal border. unilateral incision is sufficient. Three tunnels are
6. Columellar retraction - This is seen often when created as shown in the figure below.
the caudal strip of cartilage is not preserved
7. Persistence of deviation - Usually is the result Exposure:
of incomplete surgery
8. Flapping septum - This is due too much remov- The cartilaginous and bony septum are exposed
al of septal framework. The septum flaps to either by complete elevation of a mucosal flap on one
side during respiration side only. Since the flap is retained on the oppo-
9. Toxic shock syndrome - This is due to strep- site side the vascularity of the septum is retained
tococcal / staphylococcal infection. It should be and not compromised.
diagnosed early and managed by removal of nasal Mobilization and straightening:
pack, hydrating the patient and infusing parenter-
al antibiotics. The septal cartilage is freed from all its attach-
ments apart from the mucosal flap on the convex
Septoplasty: side.
Most of the deviations are maintained by extrin-
Septoplasty is a conservative approach to sep- sic factors such as caudal dislocation of cartilage
tal surgery. As much as the septal framework is from the vomerine groove. Mobilization alone
retained. will correct this problem. When deviations are
The mucoperichondrial / periosteal flap is ele- due to intrinsic causes like the presence of healed
vated only on one side. Anesthesia and patient fracture line then it must be excised along with a
position is the same as for SMR surgery. strip of cartilage. Bony deviations are treated ei-
ther by fracture and repositioning or by resection
of the fragment itself.

Prof Dr Balasubramanian Thiagarajan

 Image showing various tunnels that are created during septal surgery

Fixation:

The septum is maintained in its new position by

sutures and splints.

Advantages of Freer’s incision:

1. The incision is cited over thick skin making

elevation of flap easy.
2. There is minimal risk of tearing the flap
3. The whole of the nasal septum is exposed.
4. If need arises Rhinoplasty can be done by
extending the same incision to a full transfixation
one.
Image showing the use of Wright suture to pre-
vent overlap

Surgical techniques in Otolaryngology

158
Advantages of Septoplasty:

1. More conservative procedure

2. Performed even in children
3. Less risk of septal perforation
4. Less risk of septal hematoma

Prof Dr Balasubramanian Thiagarajan

 was the weakest portion of all its boundaries.
Caldwell – Luc surgery
In 1835 John Hunter popularized intranasal
Introduction: antrostomy via the inferior meatus. George W
Caldwell of New York combined both canine
Caldwell Luc surgery is approximately 120 years fossa approach and inferior meatal antrostomy
old. This surgery till recently was an important with success in managing patients with maxillary
tool in the armamentarium of an Otolaryngol- sinusitis. This work became a sensational publica-
ogist. Now the indications for this procedure is tion in 1893 (New York Medical Journal). A sim-
getting fewer and fewer with Endoscopic sinus ilar procedure was routinely performed in France
surgery becoming common. by Henry Luc in 1897. Only difference between
The fundamental concept of this surgical ap- their two procedures was that Luc performed in-
proach is to replace the diseased / scarred muco- tranasal antrostomy via the middle meatus while
sa from maxillary sinus with a new one. This is Caldwell performed inferior meatal antrostomy
easily said than done. It is fairly simple to remove via the inferior meatus. Better understanding of
diseased mucosa. New mucosa replacement is mucociliary clearance mechanism has popular-
dependent on the regenerative capacity of the ized conservative surgical procedures like:
patient. This approach can also be used to access
adjacent areas, which could be difficult to access Fess
otherwise. This procedure is not without its own Mini Fess
set of complications. It is imperative on the part Balloon sinuplasty
of the surgeon to weigh in the benefits vs compli- It should be stressed that Caldwell Luc procedure
cations before advising the patient. provides the maximum exposure of maxillary
sinuses, floor of orbit and pterygopalatine fossa.
Description of paranasal sinuses have been traced
up to the 16th century. Berenger Del Carpi an Indications:
anatomist first described the existence of parana-
sal sinuses and also infections involving this area. 1. Mycotic maxillary sinusitis
Detailed description of maxillary sinusitis was 2. Multiseptate maxillary sinus mucocele
first provided by Nathaniel Highmore. Maxil- 3. A/C polyp (Recurrent)
lary sinuses hence bear the name “Antrum of 4. Oroantral fistula
Highmore”. He first attempted to drain the infect- 5. Revision procedures
ed sinus cavity by inserting a silver needle (bod- 6. Access for transantral sphenoidectomy, orbital
kin) through an empty tooth socket. By doing decompression, orbital floor repair, exploration of
this he was able to enter into the maxillary sinus pterygoplatine fossa
cavity and was able to drain infected pus from it. 7. Excision of tumors involving the antrum (in-
Many surgeons used this approach to drain max- verted papilloma)
illary sinuses. It was Lamorier in 1743 and De- 8. Visualization of orbital floor during orbital
sault in 1798 who successfully demonstrated that floor decompression surgeries
maxillary sinus cavity could be approached via 9. Removal of foreign bodies from maxillary
the canine fossa route. According to them this antrum

Surgical techniques in Otolaryngology

160
In patients with severe mucociliary irreversible
damage (Kartagener’s syndrome, Young’s syn- The adult maxillary sinus is about:
drome) this could be the only approach to drain
infected material from maxillary sinuses. 25-35 mm wide
36-45 mm high
Procedure: 38-45 mm long

This surgery can be done under local / general Its average volume is about 15 ml /(one fluid
anesthesia. ounce).
Superior wall of maxillary sinus – orbital floor.
This sometimes can be dehiscent. The infraorbital
nerve is on the roof of the sinus. Medially and
posteriorly the roof is composed of the floor of
the ethmoid sinuses.

Anterior wall of maxillary sinus – This wall con-

tains the nerves and vessels that supply the upper
teeth. This wall is thinner anteriorly and it thick-
ens posterolaterally where it joins the zygomatic
process. Septae are present anteriorly in about a
third of the cases.

Medial wall – This wall separates maxillary sinus

from nasal cavity. The inferior turbinate is at-
tached along the nasal wall below the level of
maxillary sinus ostium. The nasolacrimal duct
traverses the thicker bone at the junction of medi-
al and anterior walls and it opens into
the nose below the inferior turbinate in the mid-
Image showing canine fossa area marked out in dle meatus. Maxillary sinus communicates with
a human skull the nasal cavity via the maxillary sinus ostium in
the hiatus semilunaris of the middle meatus.
The maxillary sinus is lined by ciliated columnar
epithelium. The cilia beats towards the natural Posterior wall – This is formed by the infratem-
ostium thereby moving the secretions towards the poral surface of the maxilla and it separates the
natural ostium. Hence inferior meatal antrosto- sinus from the pterygomaxillary fissure and the
my does not ensure drainage of the sinus in the pterygopalatine fossa. Pterygopalatine fossa con-
presence of normal ciliary beat. tains the internal maxillary artery and its branch-
es, pterygopalatine ganglion and
its branches.

Prof Dr Balasubramanian Thiagarajan

The dimensions of maxillary sinus cavity changes ing the periosteum from the anterior wall of max-
with age and could affect the surgery as the anat- illary sinus to avoid injury to this nerve. Branches
omy gets changed with age. The sinus expands of anterior and posterior superior alveolar nerves
at the rate of 2-3 mm / year and this process traverse through the bone to supply upper teeth
continues till adulthood. At birth maxillary sinus and gums. There is risk of injury to these nerves
is rather small and its floor lies 4 mm above the when antrostomy is extended too low. Injury to
floor of the nasal cavity. At the age of 9 the floor these nerves could cause loss of sensation of up-
of the maxillary sinuses is at the same level as that per dentition and gums.
of the nasal cavity. Their dimensions being 2x2x3
cms. In adults the sinus floor is 0.5 – 1 cm below
that of the nasal cavity. The alveolus of maxilla
atrophies in edentulous patients and the floor in
these patients could be still lower.

Anatomy of the canine fossa:

The canine fossa is the thinnest portion of the

anterior wall of the maxillary sinus. Hence it is
easy to breach this area and enter into the sinus.
Boundaries of the canine fossa include:

1. Canine eminence formed by the canine tooth –

medial
2. Root of the zygoma – laterally
3. Alveolar process of maxilla - inferiorly
4. Infraorbital foramen with the infraorbital nerve
superiorly
Image showing infraorbital nerve and its branch-
Infraorbital foramen: es

This foramen transmits infraorbital nerve, artery It should be pointed out that no significant blood
and vein. The infraorbital neurovascular bun- vessels are encountered during this surgical
dle traverses a groove in the orbital floor which procedure with the exception of small infraorbital
happens to be the roof of maxillary sinus. This vessels that exit from the infraorbital foramen.
area can also be dehiscent in some individuals. Significant bleeding is possible only when one
The neurovascular bundle exits via the infraorbit- breaches the posterior wall of the maxilla and
al foramen which is located approximately 5 mm enters the pterygopalatine fossa where internal
below the mid-portion of the inferior orbital rim maxillary artery can be encountered.
to enter the soft tissues of the cheek. Branches of
this nerve supply the lower eyelid, nose, cheek,
and upper lip. Care should be taken while elevat-

Surgical techniques in Otolaryngology

162
 xylocaine adrenaline mixture and is placed in the
sublabial area on the side of surgery. This is done
to anesthetize the mucosa over canine fossa.

Infiltration local anesthesia is preferred in this

scenario. About 1 ml of 2% xylocaine mixed with
1 in 200,000 adrenaline is infiltrated over the ca-
nine fossa area. Since the mucosa over the canine
fossa would have already been anesthetized by the
cotton pledget soaked in 4% xylocaine the process
of infiltration would invariably be painless. This
infiltration blocks them inferior orbital nerve
and its branch anterior superior alveolar nerve.
The patient is also mildly sedated to alleviate the
anxiety.

If general anesthesia is preferred then the patient

should be positioned only after the anesthetist has
intubated the patient.
Image showing canine fossa and its relevant
anatomy
Incision:
Patient preparation:
Incision is given in the Bucco gingival sulcus. The
Patient should be placed in recumbent position length of the incision could be about 3 - 4 cms.
with head slightly elevated. Nasal cavities are Ideally the incision is begun at the canine emi-
packed with cotton pledgets dipped in 4% xylo- nence and should run laterally.
caine with 1 in 100,000 adrenaline. These pledgets
should be squeezed dry before insertion. This is Langenbachs retractor is used to retract the mu-
because the critical toxic dose of xylocaine in this cosal and soft tissue to expose the anterior wall of
concentration is about 7 ml. On no account this the maxilla.
amount should be exceeded.

Under direct illumination pledgets are placed in

Inferior meatus, floor of the nasal cavity and in
the middle meatus area. At least 10 – 15 minutes
interval should be given for the drug to take its
effect.

If the surgery is planned under local anesthe-

sia then one more cotton pledget soaked in 4%

Prof Dr Balasubramanian Thiagarajan

 In the next step a periosteal elevator is used to
elevate the periosteum from the anterior wall of
maxillary sinus till the infraorbital foramen be-
comes visible. Care should be taken not to dam-
age infraorbital neurovascular bundle.

Image showing sublabial incision

The retractor should be applied in such a way that

it should not cause excessive traction to the soft
tissue in the area. Excessive traction if applied can
lead to excessive cheek oedema post operatively
which could take about a week to subside com-
pletely.

Image showing Periosteal elevator being used

to elevate periosteum from the anterior wall of
maxilla

Anterior wall of maxillary sinus antrum is opened

up using a gouge and hammer or by cutting it
using a cutting burr. The size of the antrostomy
should be 1.5 – 2 cm in diameter and more or less
circular.

Instruments can be introduced via the antros-

tomy and the diseased mucosa can be curetted
Image showing Langenbachs retractor being out under direct vision. The entire maxillary
applied sinus cavity is directly visible through the antros-
tomy opening. Of course, there could be some
blind spots which may not be fully visible i.e. the
anterior wall and the antero lateral portion of
the sinus cavity. A wide angled nasal endoscope

Surgical techniques in Otolaryngology

164
can be introduced via the antrostomy opening to maxillary antrum via inferior meatal antrostomy.
visualize even these hidden areas. One end of the ribbon gauze used to pack the
antrum is brought out via the inferior meatal an-
If the pterygopalatine fossa needs to be ap- trostomy making their later removal via the nasal
proached then the posterior wall of the maxillary cavity that much easier. Mucosal wound is closed
sinus antrum should be breached using gouge using 3-0 chromic catgut. The antral pack can be
and hammer or a cutting burr. removed via the nasal cavity after 48 hours as it is
accessible through the inferior meatal antrostomy.
Creation of naso antral window in the inferior
meatus:

This process helps in removal of antral pack after

surgical procedure. Visualization of antral cavity
is possible through this opening. Miles retrograde
gouge is used for this purpose. This gouge has a
unique curvature which will enable it to slide into
the inferior meatus.

The gouge is held in the dominant hand with Image showing antrostomy in the canine fossa
index finger serving as a guard to control the
perforation process. The gouge is slipping into the
inferior meatus. As soon as it hinges in the lateral
nasal wall the medial wall of antrum is perforat-
ed at the junction of anterior third and posterior
2/3 of inferior meatus. Its unique tip ensures that
it holds the bone fragment after perforation is
made on withdrawal. Medicated nasal pack can
be introduced via the inferior meatal antrostomy
using long-curved forceps and delivered into the

Prof Dr Balasubramanian Thiagarajan

 Image showing sublabial incision wound being
sutured with absorbable suture material

Post-operative care:

Image showing the antral mucosa via the antros- 1. Ice packs can be used over cheek to reduce
tomy oedema and discomfort
2. Nasal and antral packing can be removed be-
tween 24-48 hours
3. Nose blowing is avoided as it could cause em-
physema of cheek area
4. If patient uses denture then it should not be
worn for at least a week to facilitate mucosal
healing

Complications:

1. Oedema over cheek – This can happen if

retraction of soft tissue in the area was firm and
not gentle. Sometimes subcutaneous emphysema
Arrow indicating antrostomy opening in a CT can develop due to leakage of air from the antrum
image into the subcutaneous tissues of cheek. This com-
plication is self-limiting and will reduce within a

Surgical techniques in Otolaryngology

166
week.
2. Injury to infra orbital nerve causing anesthesia
of upper teeth and lateral wall of nose. It can even
cause pain and numbness over the face
3. Injury to nasolacrimal duct while performing
inferior meatal antrostomy
4. Devitalization of teeth due to injury to its root

Prof Dr Balasubramanian Thiagarajan

 procedure can be performed under both LA /
Endoscopic inferior meatal antrostomy GA.

Introduction:
Nasal decongestion:
Since the introduction of Functional endoscopic
surgery inferior meatal antrostomy as a procedure Nasal mucosa is decongested by using pledgets
has taken a back seat due to the apprehension soaked in 4% xylocaine mixed with 1 in 10,000
that it could tamper with the normal mucocil- adrenaline. The pledget should be squeezed dry
iary clearance mechanism. In fact studies per- before insertion. This is done to avoid xylocaine
formed in 1980’s reported that if inferior meatal over dosage. Pledgets should be placed in inferi-
antrostomy is created the mucous bridges across or meatus, floor of the nasal cavity, and middle
the antrostomy and travels towards the natural meatus. If general anesthesia is used throat pack
ostium of the maxillary sinus. This can utmost be should be given to prevent aspiration.
considered to be only partially true. Current stud-
ies have demonstrated that drainage of mucous Infiltration:
does occur via the opening created in the inferior
meatus. 2% xylocaine with `1 in 100,000 units adrenaline
is used to infiltrate the inferior turbinate and the
Current indications for inferior meatal antrosto- corresponding portion of nasal septum. 0 degree
my: nasal endoscope is
1. Patients with chronic sinusitis not responding used for purposes of visualization. A Freer’s
to FESS elevator is inserted into the inferior meatus and
2. Patients in whom mucociliary clearance is the inferior turbinate is up fractured so that it lies
already affected due to cystic fibrosis / Young’s perpendicular to the floor of the nasal cavity. This
syndrome. These patients usually benefit from procedure is a must for adequate visualization of
inferior meatal antrostomy the inferior meatal area. The location of Hasner’s
3. Mycetoma present in the maxillary sinus cavity valve (lower end of nasolacrimal duct) is identi-
4. To visualize the difficult to see areas inside fied at the junction of anterior third and middle
maxillary sinus cavity third of the lateral nasal wall.
5. When regular post op surveillance is needed

6. During Caldwell Luc procedure antral packing A 90 degree angled J curette is ideal to perform
is done via the inferior meatal antrostomy created antrostomy. The lateral nasal wall is perforated
towards the end of the surgery with J curette about 1 cm posterior to Hasner’s
valve. The opening is then enlarged with the help
Endoscopic inferior meatal antrostomy: of back biting forceps. Now insertion of a 30 de-
gree nasal endoscope will help in better visualiza-
Nasal endoscope is a very useful tool for otolar- tion of the interior of maxillary sinus cavity.
yngologist. By using this tool the whole procedure
can be performed under direct visualization. This

Surgical techniques in Otolaryngology

168
Image showing the inferior meatus after medial-
ising the inferior turbinate Image showing inferior meatal opening

Complications

1. Premature closure of the antrostomy opening

2. Failure of drainage process due to the ciliary

movements of the sinus mucosa

3. Injury to dental roots

4. Bleeding

5. Trauma to nasolacrimal duct

Image showing a J curette being used to perforate

the inferior meatus

Prof Dr Balasubramanian Thiagarajan

 ance pattern. It is hence advisable that ciliary
In inferior meatal antrostomy is useful in the mucosa in the vicinity of natural ostium is better
following ways: left undisturbed.

1. Helps / facilitates dependent drainage of max- Inferior meatal antrostomy with mucosal flap:
illary sinus in the presence of secondary ciliary
dysfunction which is a feature in persistent maxil- This procedure helps in keeping the inferior me-
lary sinus infections. atal antrostomy opening patent for a long period
of time. Keeping the antrostomy opening patent
2. It provides alternate drainage pathway to the for long durations is a necessity when the patient
maxillary sinus till the ciliary mechanism be- is suffering from primary mucociliary disorders
comes functional. preventing effective clearance of secretions from
the maxillary antrum. The sinus thus depends on
3. It helps in removal of polypoidal tissue from gravity and a patent inferior meatal antrostomy to
the maxillary sinus antrum. keep the drainage process going. Patent opening
also would be helpful if periodical viewing of the
4. Useful in breaking large retention cysts present antral cavity is needed.
in the maxillary sinus antrum.
Procedure
5. Facilitates removal of fungal debris from the
maxillary sinus cavity Under GA/LA the nasal cavity is decongest-
ed first using cotton pledgets dipped in 0.05%
6. Helps in the process of irrigation to remove oxymetazoline. Specifically the inferior meatal
thick and tenacious secretions that could be pres- area is decongested. A Freer elevator is sued to
ent within the sinus cavity. medialize the inferior turbinate.

7. Large permanent antrostomy is indicated in As a first step the lower end of naso lacrimal
patients with primary ciliary dysfunction duct (Hasner’s valve area) is identified under the
inferior turbinate. It lies roughly 15 mm above
The effectiveness of an antral window in treat- the floor of the nasal cavity and 4-6 mm poste-
ing maxillary sinusitis and the precise location rior to the anterior end of the inferior turbinate.
of such a window has always been controversial. A monopolar cautery probe or 15 blade knife is
Hilding suggested that creation of an inferior used to make an incision below and anterior to
meatal window could be detrimental to long-term the Hasner’s valve. Mucoperiosteal flap is ele-
mucociliary clearance. On the other hand Fried- vated with a Freer elevator. The inferior portion
man and Torimumi demonstrated with radio- of the medial wall of maxillary sinus is opened
nuclide studies that inferior meatal antrostomy using a Miles retrograde gouge at the level of the
does not hinder mucociliary clearance towards mucosal incision. The opening can be widened
maxillary sinus natural ostium. Studies have also using a cutting burr. After the process of widen-
revealed that widening of natural ostium leads to ing is completed then the mucosal flap is inserted
some disruption of the normal mucociliary clear- in such a way that it covers the lower border of

Surgical techniques in Otolaryngology

170
Image showing inferior meatal mucosal flap procedure. (a) The U-shaped mucosal flap was positioned
on the nasal floor after the elevation from the meatal bone; (b) The flap was positioned across the
inferior lip of the bony window into the maxillary sinus after removing bony wall. NLD, Nasolacrimal
Duct. IT, Inferior Turbinate. MT, Middle Turbinate.

the opening completely and gets inserted into the

maxillary sinus cavity.

Prof Dr Balasubramanian Thiagarajan

Vidian Neurectomy Wolff also managed to record changes in the nasal
mucosa when he interviewed psychiatric patients
Introduction: with chronic rhinitis. Turbinate biopsies from
these patients revealed hyperplasia of mucosal
Vidius in 1509 identified the vidian nerve in the glands which was filled with secretions. Lymph
floor of the sphenoid sinus while performing dis- channels were found to be dilated with predomi-
section in that area. This nerve is thought to play nant eosinophilia.
a role in the pathophysiology of rhinitis, epiph-
ora, crocodile tears, Sluder syndrome, cranial / Sectioning of greater superficial petrosal nerve as
cluster headaches. a treatment for vasomotor rhinitis was first pro-
posed by Zeilgelmann in 1934. This suggestion
In 1943 Fowler reported a rather unusual uni- was followed by Murray Falconer in 1954.
lateral vasomotor rhinitis following ipsilateral
stellate ganglion destruction. He also went to the
extent of suggesting that experimental surgeries
involving the stellate ganglion could throw light
on the fundamental mechanism of vasomotor
rhinitis. This was promptly taken up by Phil-
ip Henry Golding – Wood who suggested that
chronic vasomotor rhinitis should be considered
as simple secretomotor hyperactivity of the nasal
cavity mucosa. He concluded that emotional
stress played a role in the initiation and perpetua-
tion of vasomotor rhinitis.

Wolff in 1950 classified emotional effects on tar-

get organs as:

Stomach reactors – Who manifested with gastro-

intestinal disturbances following emotional stress

Pulse reactors – These patients showed changes in Image showing Murray Falconer
pulse rate in response to emotional stress

Nose reactors – These patients manifested with Murray Falconer’s petrosal neurectomy:
nasal congestion and discharge following emo-
tional stress. He performed this surgery under Local anesthe-
sia. The whole procedure was performed while
the patient is seated up.

Surgical techniques in Otolaryngology

172
Incision: the medial pterygoid plate. The mobilization of
mucoperichondrium extends forwards over the
Vertical incision is made above the zygoma one perpendicular plate of palatine bone. The spheno-
inch in front of the external auditory meatus. The palatine foramen comes into view and is identi-
temporalis muscle was split and the squamous fied and the vidian nerve is blindly cauterized as
portion of the temporal bone was exposed. A burr it exits from the foramen.
hole was performed in the squamous portion of
the temporal bone and the opening is enlarged till Golding – Wood’s transantral approach:
the floor of the middle cranial fossa is exposed.
The middle cranial fossa dura is gently stripped Inspired by the work of Malcomson Golding
from the floor and retracted with the help of wood started to work on the various approaches
retractors. While stripping the dura from the to vidian nerve. He popularized the transantral
middle cranial fossa it could be found attached vidian neurectomy. He considered it to be a rather
firmly to the foramen spinosum. This area could safe procedure in comparison to intracranial ap-
bleed during the dissection. The middle meninge- proach to the nerve popularized by Malcomson.
al artery which traverses this foramen was co-
agulated and cut. The foramen is plugged. From
now on the dura strips easily and the mandibular
division of trigeminal nerve is identified entering
the foramen ovale which lies medial and slightly
anterior to foramen spinosum. On stripping the
dura from the anteromedial face of petrous bone
the greater superficial petrosal nerve can be clear-
ly seen. Without causing any traction the nerve is
divided.

Malcomson in 1957 suggested that the vidian

nerve had a predominantly parasympathetic
effect. He also suggested that vidian neurecto-
my could offer relief in patients with vasomotor
rhinitis.

Malcomson’s approach to vidian nerve:

This is a rather blind approach. As a first step a Image showing Golding Wood
submucosal resection of nasal septum was per-
formed. The rostrum of sphenoid is identified. In
this area the muco-periosteum is elevated off the
anterior and inferior faces of the body of sphe-
noid. The mobilization of the mucoperiosteum is
continued laterally over to the medial surface of

Prof Dr Balasubramanian Thiagarajan

 Histological changes induced due to stimulation
In this procedure the maxillary antrum is opened of vidian nerve include:
via Caldwell Luc approach. The posterior wall of
the maxilla is identified and removed. The inter- 1.Enhanced secretory activity of nasal mucosal
nal maxillary artery can be controlled using clips. glands
The maxillary nerve is identified and traced up 2.Intense vasodilatation of deep venous plexus
to the foramen rotundum. This foramen serves 3.Increase in the periglandular blood supply
as the most important land mark in this surgical 4.Intense degranulation of mast cells
procedure. On exiting from the foramen rotun-
dum the maxillary nerve gives off branches to Acetylcholine and VIP have been implicated as
the sphenopalatine ganglion. The vidian nerve is the chemical mediators for these responses.
identified and resected here. Studies have shown
that despite there being an opening in the poste- Anatomy of vidian nerve:
rior wall of the maxilla it was not an hindrance to
wound management like antral wash etc. Accord- The vidian nerve is formed by post synaptic para-
ing to Golding – Wood even unilateral resection sympathetic fibers and presynaptic sympathetic
of vidian nerve provided relief on both sides of fibers. This is also known as the “Nerve of ptery-
the nasal cavities. goid canal”.

Golding-Wood in his classic paper on the role of Nerves that gets involved in the formation of
vidian neurectomy in the treatment of crocodile vidian nerve:
tears in 1963 observed “The only animal capable
of weeping in sorrow is the human with a doubt- 1. Greater petrosal nerve (preganglionic parasym-
ful exception to elephant.” This was in fact the pathetic fibers)
classic observation of Charles Darwin. 2. Deep petrosal nerve (post ganglionic sympa-
thetic fibers)
Effects of vidian nerve stimulation on nasal mu- 3. Ascending sphenoidal branch from otic gan-
cosa: glion Vidian nerve is formed at the junction of
greater petrosal and deep petrosal nerves.
“The parasympathetic innervation of the nasal
mucosa play a prominent role in the pathogene- This area is located in the cartilaginous substance
sis of chronic hypertrophic non allergic rhinitis”. which fills the foramen lacerum. From this area
Golding-Wood 1961. it passes forward through the pterygoid canal ac-
The vidian nerve provides the main parasympa- companied by artery of pterygoid canal. It is here
thetic supply to the nasal mucosa and maxillary the ascending branch from the otic ganglion joins
sinus mucosa. Stimulation of this nerve causes this nerve.
secretory and vasodilatory effects in animals.
The vidian nerve exits its bony canal in the ptery-
gopalatine fossa where it joins the pterygopalatine
ganglion.

Surgical techniques in Otolaryngology

174
Vidian canal: The parasympathetic fibers to the nasal muco-
sa enters the nose through the sphenopalatine
It is through this canal the vidian nerve passes. foramen. At the level of sphenopalatine ganglion
This is a short bony tunnel seen close to the floor the parasympathetic fibers synapse. Post synaptic
of sphenoid sinus. This canal transmits the vidian parasympathetic fibers from the sphenopalatine
nerve and vidian vessels from the foramen lace- ganglion arise at the pterygopalatine fossa. These
rum to the pterygopalatine fossa. post synaptic fibers are three in number. They are:

According to CT scan findings the vidian canal is 1. Nasal nerve – innervating the nasal mucosa
classified into: 2. Lacrimal nerve – innervating the lacrimal
gland
Type I: The vidian canal lies completely within 3. Greater palatine nerve – innervating the palate.
the floor of sphenoid sinus

Type II: In this type the vidian canal partially

protrudes into the floor of sphenoid sinus

Type III: Here the vidian canal is completely em-

bedded in the body of sphenoid bone

Image showing types of vidian canal

Prof Dr Balasubramanian Thiagarajan

 Image showing anatomy of the vidian nerve

Surgical techniques in Otolaryngology

176
Anatomy of sphenopalatine foramen: Indication for vidian neurectomy:

Detailed understanding of the anatomy of sphe- 1. Vasomotor rhinitis

nopalatine foramen is a must before performing 2. Intrinsic rhinitis
vidian neurectomy. This foramen is formed by the 3. Crocodile tears
articulation of the body of sphenoid and perpen-
dicular plate of palatine bone. Types of vidian neurectomy:

Boundaries: Trans septal vidian neurectomy Malcomson’s pro-

Superior – Body of sphenoid cedure is still practiced in some centers.
Anterior – Orbital process of palatine bone
Posterior – Sphenoid process of palatine bone
Inferior – Upper border of perpendicular plate of
palatine bone

This foramen is semicircular in shape and about a

quarter of an inch in diameter.
This foramen has a small notch inferiorly which
transmits the sphenopalatine artery. The naso-
palatine and superior nasal nerves also pass out
through the sphenopalatine foramen and lie
above the sphenopalatine artery.

Image showing sphenopalatine ganglion

Prof Dr Balasubramanian Thiagarajan

Transpalatal vidian neurectomy:

This procedure is performed under general anaes-

thesia, with mouth opened by Boyle Davis mouth
gag. A curved incision is made in the hard palate
2 cm anterior to the posterior end of hard palate
and the same is extended laterally and posteriorly
till the last molar. The incision is deepened up to
the underlying bone but not in the lateral aspect
in order to avoid injury to the greater palatine
vessels. The mucoperiosteum is elevated until the
palatal aponeurosis is visualised. The soft palate
is incised from the posterior part of hard palate
and nasopharynx is entered. L shaped incision is
given with the long limb above the tubal elevation
in a postero anterior direction. The short limb
of the incision is sited between the posterior and
lateral wall of nasopharynx. Elevation of mucosa
in this region exposes the medical pterygoid plate
till its attachment to the basiocciput. The medial Image showing incision for transpalatal vidian
pterygoid is drilled leaving a wedge of bone in its neurectomy
superior aspect taking care not to injure internal
carotid artery above foramen lacerum in this re- Dangers of this procedure:
gion. The pterygoid canal is visualised as a dense
ivory bone in the region of cancellous bone. It is 1. Foramen lacerum with its internal carotid ar-
usually 2 – 3mm deep. Vidian nerve is identi- tery lie close to the area of dissection
fied in this region and cauterized. Palatal wound 2. Palatal fistula is a real danger if excessive cau-
closed in layers. tery is used in that area
3. The surgery should always be performed under
Complications : continuous vision if possible microscope should
be used. 300 mm objective is preferred in order to
1. Palatal fistula can occur if excessive cautery is have an optimal working distance.
used in that area
2. Injury to internal carotid artery can occur over
foramen lacerum if medical pterygoid drilling is
done far more superiorly.

Surgical techniques in Otolaryngology

178
Transnasal preganglionic vidian neurectomy:

In this approach the pterygopalatine fossa should

be accessed.

Anatomy of pterygopalatine fossa:

This is a small pyramidal space present behind

the posterior wall of maxilla, under the orbital
apex. The posterior wall of pterygopalatine fossa
which is formed by the medial pterygoid plate has
two important openings i.e. Foramen rotundum
situated supero laterally and the funnel shaped
opening of pterygoid canal infero medial to it.
The opening of the pterygoid canal is situated
close to the medial wall of pterygopalatine fossa.
This medial wall of the pterygo palatine fossa is Image showing vidian canal as seen in trans-sep-
formed by the perpendicular plate of palatine tal approach
bone which separates this space from the nasal
cavity.
The opening of the pterygoid canal and the
The perpendicular plate of palatine bone has two sphenopalatine foramen are situated in the same
processes, the orbital process anteriorly and sphe- horizontal plane. The pterygoid canal lies in the
noidal process posteriorly with a V shaped notch posterior wall while the sphenopalatine foramen
between them. lies in the medial wall of the pterygopalatine
fossa. These two foramen are separated by small
Since these two processes articulate above with amount of bone which forms the corner between
the body of sphenoid bone this notch gets con- the two walls.
verted into sphenopalatine foramen. It is this
foramen which is important in transnasal vidian Another important land mark that is important
neurectomy. in trans nasal vidian neurectomy is the ethmoidal
crest. This lies at the posterior end of bony attach-
ment of middle turbinate.

Just behind this crest lies the sphenopalatine fora-

men. This relation ship between the crest and the
foramen is always constant.

Note: The fleshy portion of the middle turbinate

often extends a little beyond the posterior end of

Prof Dr Balasubramanian Thiagarajan

the middle turbinate.

Image showing Transverse section through right

pterygopalatine fossa showing: Endoscopic view of Ethmoidal crest

Transnasal vidian neurectomy is performed using

1. Posterior wall of maxillary antrum, 2. Pter- an operating microscope. This has been now
ygomaxillary fissure, 3. Foramen rotundum, 4. replaced with nasal endoscope. While using the
Foramen ovale, 5. Pterygoid process, 6. Sphe- operating microscope the objective should be
noid process of palatine bone, 7. Orbital pro- changed to that of 300 mm. This is a necessary
cess of palatine bone, 8. Vidian canal, 9. Sphe- step in order to ensure that the working distance
nopalatine foramen is adequate. The patient is placed supine with
head slightly elevated. The nasal mucosa and
turbinates are decongested using cotton pledgets
soaked in 4% xylocaine mixed with 1 in 10,000
adrenaline. A killians self retaining retractor is in-
serted under the middle turbinate and is opened
fracturing the middle turbinate medially. This
step is important as it provides wider access to the
middle meatus. The speculum is advanced ante-
riorly till the posterior end of the fleshy middle
turbinate is visualised. About a quarter cc of 2%
xylocaine mixed with 1 in 100,000 units adrena-
line is injected submucosally in the lateral nasal

Surgical techniques in Otolaryngology

180
wall. Endoscopic intrasphenoidal vidian neurecto-
Blanching of the area indicates adequate infiltra- my:
tion.
The preparation of patient for this procedure is
similar to that of Endoscopic sinus surgery. The
nasal cavity is decongested using a mixture of 4%
xylocaine with 1 in
10,000 adrenaline soaked pledgets.

Infiltration using 2% xylocaine mixed with 1

in 100,000 units adrenaline is performed in the
following areas:

Anterior wall of sphenoid sinus

Superior turbinates
Posterior end of middle turbinate

Step I : Lateralization of middle turbinate

This is performed under direct vision of 0 degree
4 mm nasal endoscope. This is a very important
step in this procedure. A Freer’s elevator is used
Image showing incision for endoscopic vidian for this purpose.
neurectomy
Step II : Perforation of anterior wall of sphenoid
Mucoperiosteum is incised from the lateral nasal sinus. This step is usually performed using a Fre-
wall using Rosen’s knife. The incision is a curved er’s elevator. This opening is widened inferiorly
one extending from the superior surface of infe- and laterally using Kerrison’s punch forceps.
rior turbinate in the lateral nasal wall extending The opening over the anterior face of sphenoid
up to the posterior end of middle turbinate. The sinus is widened till the vidian canal is identified.
ethmoidal crest is identified and removed expos-
ing the sphenopalatine foramen. The insulated Step III : The paper thin wall of the vidian canal is
cautery is advanced into funnel shaped opening perforated and the nerve is severed under direct
of the pterygoid canal cauterizing the nerve of vision. Bleeders if any are cauterized.
pterygoid canal. One major complication of this
surgical procedure is the development of opthal- It is mandatory to study the position of the vidian
moplegia. This is due to the probe sinking deep canal within the sphenoid sinus by doing a CT
into the pterygoid canal damaging the near by scan. If this is not done then the variations in the
abducent nerve. position of vidian canal inside the sphenoidal
sinus will create problems during surgery.

Prof Dr Balasubramanian Thiagarajan

Endoscopic posterior nasal neurectomy:

In this procedure which is performed under di-

rect endoscopic vision the posterior superior and
posterior inferior nasal nerves are resected when
they come out of the sphenopalatine foramen.

The preparation is the same as for other endo-

scopic sinus surgical procedures.

Incision: A curved incision about 1.5 cms long

is made in the middle meatus from the posterior
end of superior margin of inferior turbinate to
the horizontal portion of the ground lamella of
the middle turbinate. The dissected mucoperios-
teal lining is folded back until the sphenopalatine
foramen and the superior portion of the perpen-
dicular plate of palatine bone is exposed. The
sphenopalatine artery is identified and separated Image showing Posterior superior and posterior
out of the way. The posterior superior and postero inferior nasal nerves held under the probe
inferior nasal nerves are sectioned and bleeders if
any are cauterized.

Image showing sphenopalatine artery exiting out Image showing sphenopalatine nerve
of sphenopalatine foramen

Surgical techniques in Otolaryngology

182
Complications of vidian neurectomy: sphenopalatine foramen is widened towards the
anterior face of sphenoid. The thin anterior wall
1. Dry eye due to decreased lacrimation of sphenoid sinus is penetrated using the Freer’s
2. Neurotorphic keratopathy elevator. The floor of the sphenoid sinus should
3. Ocular movement disturbances be visualized to study the course of the vidian
4. Blindness nerve.

Endoscopic vidian neurectomy: The vidian canal lies at the junction between the
floor of the sphenoid sinus and the lateral nasal
This procedure is performed under endoscopic wall. The vidian canal should not be confused
vision. Patient preparation is the same as for other with that of palatovaginal canal. Palatovaginal
endoscopic sinus surgical procedures. A curved canal which contains pharyngeal branches of the
suction tip is used to maxillary artery and pterygopalatine ganglion lies
palpate the lateral nasal wall behind the uncinate inferomedial to the vidian canal. The vidian nerve
and above the insertion of the inferior turbinate is exposed, resected and bleeders if any is coagu-
in order to identify the soft membranous portion lated.
of the posterior
fontanelle of the maxilla. On moving the suction Treatment of crocodile tears with vidian neu-
tip posterior to the posterior fontanelle, the hard rectomy:
bony anterior edge of palatine bone can be identi-
fied. A C shaped incision is made using a 15 blade This term crocodile tears was coined by Bogorad
at the junction between the posterior fontanelle to describe the unusual phenomenon of profuse
and the palatine bone. The incision starts just lacrimation which occurs during eating only. He
below the horizontal portion of the basal lamella coined this term because it was believed croco-
and ends just above the insertion of inferior tur- diles shed tears before devouring their prey. This
binate in the lateral nasal wall. condition could be a sequel to facial palsy.

Caution: The incision should not extend into the Other causes of crocodile tears include:
maxillary sinus via the posterior fontanelle.
1. Head injury
A posterior based mucoperiosteal flap is raised 2. Operative trauma
using a Freer’s elevator, exposing the palatine 3. Syphilitic lesion of geniculate ganglion
bone. During 3-4 mm of dissection the flap is
raised over the entire length of the incision. After This condition occurs due to anomalous regen-
this level the flap is raised only along the lower eration causing the secretomotor fibers from the
third of the incision i.e. just above the insertion of corda tympani nerve reaches the lacrimal gland
the inferior turbinate. This dissection is continued via the greater superficial petrosal nerve.
posteriorly till the anterior face of sphenoid sinus
is reached. Now the dissection proceeds upwards
exposing the ethmoidal crest and the underlying
sphenopalatine artery. The posterior rim of the

Prof Dr Balasubramanian Thiagarajan

Is vidian neurectomy really useful?

This question is yet to be categorically answered.

In my personal experience I have performed
about 10 vidian neurectomies. Out of this num-
ber about 6 patients had questionable relief of
symptoms.

Interesting questions to be answered.

Should you perform bilateral vidian neurectomy

for significant relief of symptoms?
If performed there is a significant risk of dryness
of eye due to diminished lacrimation.

The only advantage of this procedure is that this

makes the operating surgeon more competent in
performing endoscopic skull base surgical proce-
dures.

Surgical techniques in Otolaryngology

184
Approaches to frontal sinus tomical constraints.

History of frontal sinus surgery History of frontal sinus surgery can be divided
into following era:
The first frontal sinus procedure was described in
1750. Despite more than two centuries since the 1. Era of trephination (1750)
description of the first procedure on frontal sinus,
the optimal procedure to access frontal sinus still 2. Era of radical ablation procedures (1895)
remains unclear. The frontal sinus surgery makes
up only a small portion of all surgeries involving 3. Era of conservative procedures (1905)
paranasal sinuses. Ellis in 1954 stated that “surgi-
cal treatment of chronic frontal sinusitis is diffi- 4. External fronto-ethmoidectomy (1897-1921)
cult, often unsatisfactory and sometimes disas-
trous. The sheer number of surgical techniques 5. Osteoplastic anterior wall approach (1958)
available are expressions of our uncertainty and
perhaps also our failure.” 6. Endoscopic intranasal approach

Ideal treatment for diseases involving frontal

sinus is the one that will provide complete relief Trephination Era:
of symptoms, eradicate the underlying disease
process, preserve the function of the sinus and Frontal sinus surgery was first described in the
cause the least morbidity and the least cosmetic 18th century. As early as 1750 Runge performed
deformity. an obliteration procedure of the frontal sinus. In
1870 Wells described an external and intracranial
Over the last two centuries a variety of surgical drainage procedure for frontal sinus mucocele. In
procedures have been described for the treatment 1884, Alexander Ogston described a trephination
of frontal sinus disease. These procedures includ- procedure through the anterior table to evacuate
ed external and intranasal approaches. Despite the frontal sinus. He also dilated the nasal frontal
the fact that over the years the incidence of com- duct, curetted the mucosa and established drain-
plications have decreased, orbital and intracranial age with a tube that was placed in the duct. At
complications, including meningitis, subdural the same time Luc described a similar procedure,
abscess, intra-cerebral abscess and osteomyelitis and two years later the Ogston-Luc procedure
continue to occur. did not gain popularity because of the high failure
rate due to nasal frontal duct stenosis.

Osteoplastic flap has been the mainstay of surgi- Radical ablation procedures (1895)
cal access to the frontal sinus. With advances in
the field of imaging and endoscopy, a new fron- During this era a number of physicians were
tier (intranasal approach) has become popular. advocating a radical procedure to clear frontal
Assessing the frontal sinus is a greater surgical sinus disease. In 1895 Kuhnt described a proce-
challenge than other sinuses owing to the ana- dure where in he removed the anterior wall of the

Prof Dr Balasubramanian Thiagarajan

frontal sinus in an attempt to clear the disease. and ventilation of the frontal sinus. Numerous
The mucosa was stripped to the level of frontal re- complications were encountered which includ-
cess and a stent was placed for temporary drain- ed intracranial penetration. Between 1901 and
age. In 1898 Riedel described the first procedure 1908, Ingals, Halle, Good, and Wells described
for obliteration of frontal sinus which involved several intranasal procedures to the frontal sinus.
complete removal of anterior table of frontal sinus Halle described a procedure in which the frontal
with mucosal stripping. This procedure had the process of maxilla was chiseled out and a burr
advantage of removing osteomyelitic bone as well was used to remove the floor of the frontal sinus.
as allowing for easy detection of recurrent dis- This surgery was rarely used because of its associ-
ease. This procedure caused unsightly deformity ated high mortality rate. The increased incidence
of forehead. In 1903 Killian described a modifi- of mortality and complications was the result of
cation of the Riedel procedure. In an attempt to inadequate visualization of the frontal recess.
minimize the cosmetic deformity he recommend-
ed preserving a one centimeter bar of the supra- In 1914 Lothrop described a procedure to enlarge
orbital rim. He also recommended an ethmoid- the frontal sinus pathway in a way that could
ectomy with rotation of a mucosal flap into the prevent restenosis as well as closure. The proce-
frontal recess with stenting to prevent stenosis. dure described a combined intranasal ethmoid-
Killian’s technique became popular during this ectomy and an external ethmoid approach to
era because it of the reduced incidence of cosmet- create a common frontal nasal communication by
ic deformity. This technique became unpopular resecting the frontal sinus floor and frontal sinus
later because of the high incidence of late morbid- septum and the superior portion of nasal septum.
ity with restenosis, supraorbital rim necrosis, post Lothrop admitted that due to lack of visualization
operative meningitis, and mucocele formation as during intranasal approach made the procedure
well as death. rather dangerous. Follow up of these patients
demonstrated that resection of the medial orbital
Conservative procedures (1905) wall allowed the collapse of orbital soft tissue into
the ethmoid area with subsequent stenosis of the
Since there is significant cosmetic deformity as frontal drainage pathway.
well as high failure rate external ablative pro-
cedures became rather uncommon and were Frontal sinus trephining
abandoned in favor of intranasal conservative
approaches and external frontoethmoidal tech- Definition:
niques. In 1908 Knapp described an ethmoid-
ectomy through the medial wall and entering Trephination of frontal sinus is a surgical pro-
the frontal sinus through its floor. He managed cedure where in a small opening is made in the
to remove diseased mucosa and enlarged the floor of frontal sinus facilitating drainage of its
naso-frontal duct. This surgery however did not contents.
receive wide attention.
History: Trephination of frontal sinus is nothing
In 1911, Schaeffer proposed an intranasal punc- new. It dates back to prehistoric times. Two Peru-
ture technique to re-establish the drainage vian skulls at the Museum of Man in San Diego

Surgical techniques in Otolaryngology

186
show evidence of frontal trephination.

Indications of frontal sinus trephining:

1. Acute sinusitis not responding to medical man-

agement

2. Can be used to identify frontal sinus opening

inside the nasal cavity during endoscopic sinus
surgery

3. To prevent stenosis of the frontal sinus infun-

dibulum after endoscopic sinus surgery

Procedure:

Before the actual procedure the size of the frontal

sinus must be assessed by taking a occipito frontal
plain radiograph. This view will actually demon- Image showing a Trephining kit
strate the size of frontal sinus. This procedure is a
must as it will help in deciding where to place the
opening.

Anesthesia:

This procedure can be carried out under both lo-

cal or general anesthesia. Commonly local anes-
thesia is preferred as it provides a relatively blood
less field.

2% xylocaine admixed with 1 in 10,0000 units

adrenaline is used as infiltrating agent. This mix-
ture has the advantage of providing anesthesia
as well as local vasoconstriction of blood vessels.
About 1/2 ml of this solution is infiltrated over
the trochlear nerve area (skin over the antero in-
ferior part of forehead). 10 minutes is given after
the injection for the drug to take effect.
Image showing the site of trephination

Prof Dr Balasubramanian Thiagarajan

The point of trephenation is located as shown . Slow irrigation of the cavity
in the figure above. A horizontal line is drawn
between the superior limit of each orbit. Another Most of the complications following frontal
vertical line is drawn to intersect this horizontal trephination results from unfavorable anatomical
line exactly in the midline. The point of perfora- conditions. To avoid serious complications treph-
tion is located about 1 cm lateral to this midline. ination should not be performed if the pneuma-
This depends on the size of the sinus and the tization of the frontal sinus does not reach the
location of the inter-sinus septum. superior limit of the orbit. In these condition
trephination is not of much help since the fron-
No incision is necessary. A small puncture is tal sinus itself is pretty rudimentary and can be
made at this site using a hand drill. After perfo- accessed intra nasally using an endoscope.
rating the skin, the drill bit comes into contact
with the bone. Bone in this area is drilled out. 1. Brain injury
Hand drill is preferred since the power drills
reduce the sensitivity of the surgeon who is drill- 2. Cellulitis
ing making him loose control. Once the bone is
penetrated a needle made of teflon is put in place. 3. Orbital complications due to needle shift (com-
A small catheter can be connected to this needle mon in home environment)
and wash can be given using a syringe. Before
starting the irrigation procedure it must be ascer- Endoscopic frontal sinus surgery
tained whether the teflon needle is really inside
the frontal sinus. This can be done by visualising This surgery is commonly performed to drain
air bubbles when the syringe filled with saline is the obstructed frontal sinus. This surgery is
connected to the catheter. Initially irrigation is performed under general anesthesia. Cotton
done slowly under endoscopic control. pledgets soaked in 4% xylocaine with 1 in 1 lakh
units adrenaline is placed under superior, middle
Complications: and inferior meatus and allowed to be in place for
about 10 minutes before intubation. The patient
Complications can be avoided by following the is positioned with 20-30 degree elevation and
guidelines given below: gentle extension of the head. Nasal endoscopy is
performed using 30 degrees, 45 degrees and 70
Guidelines for safe frontal irrigation: degrees nasal endoscope.

. Radiographic evaluation of the size of frontal Steps of the surgery include:

sinus cavity
Uncinectomy
. Meticulous location of the site of trephination
Anterior ethmoidectomy
. Control with aspiration of a good needle posi-
tion before irrigation Complete frontoethmoidectomy

Surgical techniques in Otolaryngology

188
 It represents superior and lateral pneumatization
Resection of agger nasi and anterosuperior of the anterior ethmoidal cell. This accounts for
attachment of the middle turbinate is needed the significant variation in frontal sinus anato-
to create a widely patent frontal recess. Ostium my. These include variations such as agger nasi
probe / ball probe is used to locate the outflow cell penumatization, prominent ethmoidal bullae
tract. The nasofrontal beak which is shelf like and supraorbital cells. Ethmoidal air cells may
bony process anterior to the frontal outflow tract be contained wholly within the frontal recess /
can be removed using a Kerrison rongeur / drill / frontal sinus and are termed frontal cells.
curette.
Bent’s classification of accessory frontal cells:
Further drainage would require removal of the
superior aspect of the nasal septum, this is need- The classification proposed by Bent grouped
ed if a bilateral frontal sinus drill out is desired. these cells into four different types based on their
In order to allow re-epithelialization, the surgeon location.
must not remove the posterior table mucosa.
Mucosal preservation is of utmost importance in Type I: This type represents a single frontal cell
routine, uncomplicated frontal sinus surgery. just above the agger nasi cell

A frontal sinus stent can be used in more compli- Type II: This type consists of a tier of two or more
cated cases where mucosal preservation may be air cells superior to the agger nasi cell.
difficult and typically when the neo-ostium is less
than 5 mm in diameter. Type III: This type has a single frontal cell which
is massive and it pneumatizes superiorly into the
FESS can also be used with trephination in the frontal sinus
presence of thick secretions, high frontal cells
within the sinus, and lateralized frontal sinus Type IV: These cells are contained entirely within
disease. Extended drainage of the sinus can be the frontal sinus, thus giving it a cell inside a cell
achieved by means of resection of the frontal appearance.
sinus floor.
Among these types III and IV are considered to
be invasive types.

Draf procedures Supraorbital cells: These cell pneumatize the

orbital plate of the frontal bone posterior to
Frontal sinus anatomy is highly variable. This in- the frontal recess and lateral to the frontal si-
cludes variation of the pneumatization within the nus. These cells appear to extend over the orbit,
frontal sinus itself and of the surrounding ante- appearing as the lateral cell in a coronal CT scan.
rior ethmoid cells. These variations have been de- Endoscopically these cells appear as separate ostia
scribed as causes of frontal sinus obstruction and present along the anterolateral aspect of the roof
resultant frontal sinus disease. Embryologically of the ethmoid. These cells lie postero lateral to
frontal sinus is the last paranasal sinus to develop. the frontal sinus ostia and anterior to the anterior

Prof Dr Balasubramanian Thiagarajan

ethmoidal artery.
Failure of medical therapy warrants CT imag-
Intersinus septal cell: is a midline cell that pneu- ing and evaluation for surgery. One important
matizes the frontal bone between the two frontal aspect when considering indications for frontal
sinuses. sinus surgery is selecting the appropriate proce-
dure. Majority of primary surgical procedures
for chronic rhinosinusitis can be addressed by
a limited endoscopic sinusotomy which include
Draf 1 or 2A procedure. More challenging would
be identification of indications for an extended
endoscopic approach. Neo-osteogenesis and lat-
eralized middle turbinate are also potential indi-
cations for extended approaches. This condition
is the most common indication for an extended
endoscopic approach. Presence of a mucocele
may also necessitate an extended endoscopic
approach.

Anomalous frontal sinus anatomy including type

III and IV frontal cells can also be an indication
for extended approaches.

Narrow anterior-posterior dimension at the naso-

frontal beak could be a relative contraindication
for these extended approaches.
Image showing type II frontal cell

Indications for surgery Draf 1 procedure

1. Chronic frontal sinusitis Endoscopic approaches to frontal sinus is consid-

ered to be the accepted one. These approaches
2. CSF leak have been found to be effective in a diversity of
pathology, including laterally based lesions. The
3. Benign and malignant tumors of frontal sinuses classification system used to classify different
frontal sinus surgical approaches was described
Surgery should typically follow maximal medical by Draf in 1991. Other procedures like frontal
therapy. sinus rescue procedure as well as frontal balloon
catheter dilatation have also been described re-
Maximal medical therapy should include intrana- cently.
sal steroids, saline irrigations, oral antibiotics and
oral steroids. In Draf 1 procedure the frontal recess and infun-

Surgical techniques in Otolaryngology

190
dibulum are cleared first. This procedure involves
removing the superior portion of the uncinate Draf 2 Procedure
process, the anterior ethmoid cells and cells with-
in the frontal recess. Agger nasi cell is preserved Draf 2A and 2B procedures differ from Draf 1
in Draf 1 procedure. In this procedure the nar- procedure in that all cells within the frontal sinus
rowest part of the frontal recess is not manipulat- are cleared with direct opening of the internal
ed, structures inferior to the internal frontal sinus frontal sinus ostium. In Draf 2A procedure all
ostium are cleared. cells within the frontal recess lateral to the middle
turbinate attachment are opened in addition to
the structures cleared in Draf 1 procedure. A large
number of primary cases and many revision cases
as well can be addressed by Draf 2 technique.

Image showing Draf type I drainage procedure.

Image showing Draf type 2 a drainage procedure
1. Nasal septum
Draf 2B procedure involves extension of Draf 2A
2. Middle turbinate procedure to include the entire ipsilateral floor of
the frontal sinus. This includes removal of middle
3. Medial orbital wall turbinate attachment to the frontal sinus floor ex-
tending the dissection in a medial direction, with
4. Intersinus septum the nasal septum and intersinus septum being
the medial extent of dissection. This procedure is
considered more aggressive and potentially risky
due to dissection adjacent to the cribriform plate
and the potential for destabilization of the middle
turbinate.

Prof Dr Balasubramanian Thiagarajan

Image showing Draf type 2b drainage procedure

Draf 3 procedure creates a single common drain-

age pathway for bilateral frontal sinuses. Frontal
sinus drill out and Endoscopic modified Lothrop
procedures are synonyms for the same procedure.
This procedure involves clearing of all structures
as done for Draf 2B plus the removal of the in-
tersinus septum and superior nasal septum. This Image showing upper end of uncinate process
procedure mandates the use of an angulated drill being removed
to ensure adequate removal of bone at the ante-
rior aspect of the common frontal neo-ostium.
The decision to proceed to extended endoscopic
frontal sinus procedures, including the Draf 2 B
and 3 procedures, is typically the result of severe
disease within the nasofrontal duct. This includes
neo-osteogenesis, osteitis and mucosal stenosis.
Anatomical considerations, including the pres-
ence of a lateralized middle turbinate / a promi-
nent nasofrontal beak can also influence the de-
cision to proceed with Draf 2 B and 3 procedures.
Draf 3 procedure could be an useful alternative
to external approaches for those situations like
difficult and recalcitrant frontal sinus disease.

Image showing agger nasi being deroofed

Surgical techniques in Otolaryngology

192
Image showing agger nasi air cell after deroofing Image showing the deroofed agger nasi and the
frontal outflow tract that lies medial to it. The
lateral wall of agger nasi should be removed to
clear the area

Image showing ball probe introduced into frontal

recess area
Image showing discharge flowing out of frontal
sinus

Prof Dr Balasubramanian Thiagarajan

Image showing thick tenacious secretion flowing
out of frontal sinus Image showing frontal sinus as seen via widened
frontal sinus ostium.

Image showing suction tip inside frontal sinus

opening

Image showing the end result of Draf 3 procedure

Surgical techniques in Otolaryngology

194
 scans)
Frontal sinus rescue
5. 65 degrees mushroom punch is useful in fron-
This procedure was first described by Citardi in tal recess dissection
1997. This was considered to be an alternative to
Draf 3 procedure / external frontal sinus oblit- 6. Hosemann punch which is an angulated mush-
eration in certain situations. This procedure is room punch with greater cutting strength is use-
intended to correct iatrogenic scarring of the ful for clearing osteitic bone from frontal recess.
frontal ostium making the sinus safe by prevent-
ing mucocele formation. The technique of this 7. Bachert / cobra forceps can be used to clear
procedure involves transposing a laterally based agger nasi and frontal recess cells
mucosal flap from the middle turbinate rem-
nant on to the medial skull base. A longitudinal 8. Powered instrumentation with angled drills is
incision is made in the middle turbinate remnant typically used when performing extended endo-
and lateral mucosal flaps are raised. The medial scopic approaches like that of Draf 3 procedure.
flap is resected along with the continuous mu-
cosa on the anterior skull base. The bony middle
turbinate remnant is then resected. The lateral
flap is then turned into the area of the previously
resected mucosa along the anterior skull base.
This procedure has the advantage of changing
the circumferential scar of the frontal duct into a
geometrical pattern for prevention of recurrent
scar formation.

One common element in various endoscop-

ic frontal sinus surgeries is the preservation of
mucosa within the nasofrontal duct in order to
prevent postoperative stenosis.
Image showing 45 degree mushroom punch
Scientific advances that play an important role in
the development of modern frontal sinus surgery:

1. Advances in optics and rod lens system

2. Instrumentation enabling image guided sur-

gery

3. High quality angled endoscopes

4. Advances in CT imaging (enabling thin section

Prof Dr Balasubramanian Thiagarajan

 (0.5mg/2ml) can be added to saline irrigations.
Oral regimens of postoperative prednisolone
(0.1mg/kg) and antibiotics are sometimes recom-
mended for several days postoperatively.

Debridement is an essential part of complete

postoperative care. Patients are seen 1 week post-
operatively for the first debridement under topical
anesthesia. The frontal recess area is suctioned
free of mucous / clot / crusting / bone fragments.
Crusts can be removed with forceps. Care is
taken not to cause excessive mucosal bleeding. If
purulence is encountered during postoperative
debridement, cultures can be taken and culture
specific antibiotics can be prescribed. It takes
approximately 12 weeks for the frontal recess area
to be fully healed.
Image showing Cobra forceps in action
Complications

Stenting of frontal sinus could be useful in pre- 1. Injury to periorbit

serving the results of surgical dilatation of frontal
sinus. A completed operation without stenting 2. Dural injury
resulted in complete obstruction of the duct. Cur-
rently silicone sheeting can be cut to shape and 3. Smell disturbance post operatively
inserted endoscopically to promote mucosaliza-
tion and patency following extended frontal sinus Endoscope assisted external approach to clear
surgeries. These stents can easily be removed in lateral lesions of frontal sinus
the outpatient setting after several weeks post
operatively. Surgery involving the frontal recess area and
frontal sinus still remains a challenge due to their
Post operative care complex and variable anatomy. Hence selection
of an appropriate approach depending upon
This is vital in preserving surgical results. Typ- the nature and site of the pathology is of utmost
ically they include topical irrigations as well as importance. Most of the lesions in ethmoids and
possible oral medications. Saline irrigations are sphenoid can be repaired endoscopically, but
begun on post operative day 1 and performed 3 the same is not true for lesions involving frontal
times daily for the first week. It can be decreased sinuses.
to once a day for another 6-12 weeks. If aller-
gic fungal sinusitis / substantial nasal polyposis Before the advent of endoscopic surgical proce-
is present, topical steroid such as budesonide dures, external techniques like frontoethmoidec-

Surgical techniques in Otolaryngology

196
tomy, osteoplastic flap with obliteration of frontal
sinus could be used to treat lesions of frontal 4. Complicated acute frontal sinusitis
sinus.
5. Pott’s puffy tumor
Patients with pathology in frontal sinus whose le-
sions are inaccessible with endoscope by endona- 6. Lateral frontal sinus mucocele
sal approach alone should be considered for this
approach. Preoperative evaluation which include 7. Repair of frontal sinus CSF leak
CT and MRI should be performed to ascertain
the suitability of the procedure. 8. Removal of osteoma

Procedure 9. Frontal sinus obliteration

A mini brow incision is made lateral to the su- Classic frontoethmoidectomy involves removing
praorbital foramen. Periosteum is incised and the lamina papyracea, opening and stripping the
the underlying bone is exposed. In case of CSF mucosa from the ethmoid sinuses up to cribri-
leak from the posterior table of the frontal sinus form plate, nibbling away the lateral wall of the
a bony window is made with 4 mm cutting burr frontonasal duct and floor of frontal sinus and
in the anterior wall of frontal sinus which can be stripping the mucosa from the frontal sinus.
enlarged as per requirement. Maximum width
of the window should not exceed 10 mm. The The classic external frontoethmoidectomy howev-
endoscope is inserted through the brow incision er is contrary to modern principles of endoscopic
and the interior of frontal sinus is examined. This sinus surgery which include:
window can be used to secure access to the fron-
tal sinus cavity. 1. Limiting surgery to diseased sinuses

External frontoethmoidectomy 2. Mucosal sparing

External approaches to frontal and ethmoid 3. Avoiding surgery to the frontal recess and fron-
sinuses are rarely used these days. This procedure tonasal duct
is performed only in centers in the developing
world where endoscopic sinus surgery expertise 4. Preserving middle turbinate
and instrumentation are not available.
5. Limiting resection of lamina papyracea to avoid
Indications for open approaches: medial prolapse of orbital soft tissues

1. Drainage of orbital abscess

2. Ethmoid artery ligation for intractable epistaxis

3. Biopsy of tumors

Prof Dr Balasubramanian Thiagarajan

 comes effectively obliterated by prolapsing perior-
Sewall-Boyden flap usage in external frontal bita. Stenting can delay, but will not prevent this
sinusotomy settling from occurring. This delay of course can
promote mucosalization of the area which may be
adequate for patency. This of course is not reli-
able.
Traditional external frontoethmoidectomy ap-
proaches have fallen out of favor because of The area of nasofrontal duct should be widened
unpredictable rates of frontal recess stenosis. This to ensure success and it should be performed by
is caused by the lack of mucosal preservation in removal of thick bone of the nasal process of the
the critical area of frontal recess. Sewall-Boyden frontal bone, frontal process of the maxilla and
flap is a modified external technique that creates the lateral half of nasal bone. The mucoperiosteal
mucosal coverage of the frontal recess area via a flap can then redrape itself easily into the sinus
medially based mucoperiosteal flap which yields without causing obstruction to the duct. The flap
a high degree of long term frontal sinus patency. itself comes from the anterior mucoperiosteum
Sewall-Boyden flap is a modified external tech- underlying the nasal bone and ascending process
nique that creates mucosal coverage of the frontal of maxilla. Based on the upper anterior septum,
recess via a medially based mucoperiosteal flap its axis of rotation is anterior to the original na-
which yields a high degree of long term frontal sofrontal duct. The bone of the nasal process of
sinus patency. This procedure can easily be per- the frontal bone and ascending process of maxilla
formed unilaterally with minimal morbidity. are therefore in the way of this axis and must be
removed in an anterior direction to allow the flap
Surgical technique to rotate smoothly and lie flush against the medial
frontal sinus. This step if performed diligently,
The success of this procedure is based on two the new duct is wide enough and the flap is of
concepts: sufficient length to lie comfortably in position
without a stent.
1. Creation of a wide new nasofrontal duct by
adequate bone removal. Surgical steps:

2. Lining of nasofrontal duct with a broad, septal- Step 1:

ly based mucoperiosteal flap.
Anterior external ethmoidectomy is first per-
Both these concepts are of equal importance. The formed. The extent of ethmoidectomy is deter-
problem is that the space for a new nasofrontal mined by the degree of the disease present and
duct cannot be obtained in a lateral direction the surgeon’s belief. The periorbita should be
despite the removal of a large amount of bone in elevated superiorly up the level of the supraorbital
the ethmoid region and the floor of the frontal notch to provide adequate exposure to the floor of
sinus. This is because the periorbita settles back the frontal sinus. This step involves detachment
medially and superiorly to its original position. of trochlea with the periorbita. It subsequently
The extra space created by drilling laterally be- returns to its original preop position. There have

Surgical techniques in Otolaryngology

198
not been any problems with persistent diplopia
as a result of this. Soft tissues over the nose on
the medial edge of the incision are elevated to the
midline of the nasal dorsum and caudally to the
end of the ipsilateral nasal bone, thereby exposing
the entire ipsilateral nasal bone.

Step 2:

The ethmoid sinuses are entered through the lac-

rimal fossa and exenterated posteriorly from this
location. The bone of the frontal process of the
maxilla and anterior lacrimal crest are left undis-
turbed at this point. Every effort should be made
to remove all bony septa and the lamina papyra-
cea to the level of the roof of the ethmoid sinuses.
Working forward along the roof of the ethmoid
sinuses frontal sinus can be entered. Its floor is
removed as far laterally as the supraorbital notch
and as far anteriorly as the supraorbital rim.
Kerrison rongeurs are useful for this purpose. All
abnormal mucosa is removed and the location of
the intersinus septum is noted. A minimum of Image showing bone removal in Sewall-Boyden
the anterior half of the middle turbinate is re- procedure
moved and its attachment is trimmed completely.
After injecting a suitable hemostatic solution like Step 3
1 in 100,000 adrenaline a cottle elevator is used to
develop a plane between the nasal bone and the The elevated mucoperiosteum is carefully pro-
underlying mucoperiosteum, beginning at the tected while using Kerrison rongeurs to remove
junction of the nasal bone and the upper lateral the lateral half of the nasal bone and the frontal
cartilage. This plane extends laterally underneath process of the maxilla working from inferior
the frontal process of the maxilla to connect with to superior. With increased exposure provided
the ethmoidectomy defect. The upper lateral by this bone removal, the mucoperiosteum is
cartilage is detached by necessity from the lateral carefully elevated off the roof of the nose at its
half of the nasal bone but remains attached me- attachment with the upper septum. The mucosa
dially and to the septum, thus retaining its posi- is protected with an elevator, while the triangle of
tion and the relationships of the nasal valve. The thick bone of the nasal process of the frontal bone
removal of the lateral half of the nasal bone has is removed to make it flush with the nasal septum.
not caused any external deformity. This maneuver will completely reveal the origi-
nal nasofrontal recess, which is often filled with
polypoidal mucosa. This mucosa, as well as the

Prof Dr Balasubramanian Thiagarajan

mucosa of the medial sinus where the flap will lie
is removed. A scalpel is used to incise the muco-
periosteum distally at its junction with the upper
lateral cartilage. The incision is continued lateral-
ly to connect with the ethmoidectomy defect.

Step 4

Working cephalad along the edge of the remain-

ing nasal bone, a flap is cut sufficiently medially
to allow it to rotate comfortably and lie on the
medial half of the reconstructed nasofrontal duct.
The pedicle must be kept broad enough to main- Image showing the effects of Sewall-Boyden sur-
tain its blood supply. The flap should be trimmed gery. The first picture is preop and the next one
if it is too long to fit in the frontal sinus along the is post op.
intersinus septum or it its distal portion contains
polypoid degenerative mucosal changes.

The need for nasal packing is determined by the

amount of bleeding present and the preference
of the surgeon. If packing is resorted to it must
be ensured that it should not extend up into the
frontal sinus to lay up against the flap as it could
dislodge the flap.

Post op care involves saline irrigation, usually

beginning on the second or third post op day.
Frequent crust removal in the out patient set-
ting is recommended to prevent development of
synechiae.

Surgical techniques in Otolaryngology

200
Endoscopic frontal sinus surgery (Agger nasi
approach)

The introduction of endoscopic sinus surgery

techniques allowed re-establishment of venti-
lation and drainage function of the paranasal
sinuses. Conventional endoscopic frontal sinus
surgery is able to deal with a majority of chronic
frontal sinusitis. Recurrent / persistent frontal
sinus disease caused by scarring / stenosis could
be really challenging for the surgeon.

Procedure
I Image
Endoscopic frontal sinus surgery is performed
under general anesthesia. Patient is positioned Image showing the incision over the agger nasi
supine in the operating table with the head slight- area
ly lowered. The operative procedure is usually
performed using image guidance using a wide
angled 0 degree nasal endoscope. Incision is
positioned over the agger mucosa. The mucosa is
separated to expose the bony surface of the fron-
tomaxillary process and attachment of the middle
turbinate. The bone of frontomaxillary process is
drilled directly upward between the orbital plate
of the ethmoid bone and attachment of the mid-
dle turbinate. The bone of frontomaxillary pro-
cess is directly drilled out upwards between the
orbital plate of ethmoid bone and attachment of
middle turbinate using angled diamond burrs and
then the anterior upper attachment of uncinate
process and agger cells should be fully visualized.
After removal of fragile partitions of uncinate
process, frontal recess, agger cells are removed
with curettes or fine forceps under direct visual- Image showing opening being created in the floor
ization the floor of frontal sinus is identified and of the frontal sinus under endoscopic vision.
resected using an angled diamond burr to create
a more than 6 mm frontal drainage pathway. En-
doscopic management of ethmoid, maxillary and
sphenoid sinus is performed as needed.

Prof Dr Balasubramanian Thiagarajan

 Diagnostic Nasal Endoscopy

Synonyms: DNE, Nasal endoscopy, Diagnostic

nasal endoscopy.

Introduction:

Examination of nose has been revolutionized by

the advent of nasal endoscopes. These endoscopes
are nothing but miniature telescope. It comes in
the following sizes 2.7mm, and 4mm. It comes in
various angulations namely 0 degrees, 30 degrees,
45 degrees, and 70 degrees. The 2.7 mm endo-
scope is used for diagnostic nasal endoscopy and
in children. For diagnostic nasal endoscopy it is
Image showing frontal sinus opening (blue ar- better to use a 2.7 mm 30 degree nasal endoscope
row) if available. A 4mm 30 degree nasal endoscope
can also be used for diagnostic nasal endoscopy
in adults.

Indications of diagnostic nasal endoscopy:

1. To evaluate why a patient is not responding to

medication.
2. To determine whether surgical management is
necessary.
3. To examine the results of sinus surgery
4. To determine the effects of conditions such as
severe allergies, immune deficiencies and mu-
cociliary disorders (disorders that affect mucous
membranes and cilia)
5. To determine whether a nasal obstruction (e.g.,
polyps, tumor) is present in the nasal cavity
6. To determine whether any foreign bodies (e.g.,
small object inserted by a child) are lodged in the
nasal cavity
7. To remove a nasal obstruction or foreign mate-
rial from the nasal cavity

Surgical techniques in Otolaryngology

202
8. To determine whether an infection has moved patient to swallow. The endoscope is now turned
beyond the sinuses 90 degrees in the opposite direction, the uvula
9. To diagnose chronic recurrent sinusitis in chil- and soft palate comes into view. The endoscope is
dren with asthma again rotated by 90 degrees in the same direction,
10. To diagnose reason for anosmia (loss of the opposite side pharyngeal end of eustachean
smell). tube is visualised. In this field both eustachean
11. To evaluate any discharges from the nasal tubes become visible.
cavities like CSF.
12. To diagnose reason for facial pain / headaches. Second pass:
Procedure: Topical anesthetic 4% xylocaine is
used to anesthetise the nasal cavity before the After the first pass is over, the scope is gently
procedure. About 7 ml of 4% xylocaine is mixed withdrawn out and slide medial to the middle
with 10 drops of xylometazoline. Cotton pledgets turbinate. The relation ship between the mid-
are dipped in the solution, squeezed dry and used dle turbinate and nasal septum is studied. This
to pack the nasal cavity. Pledgets are packed in relationship is classified as TS1, TS2, and TS3.
the inferior, middle and superior meati. Packs are It depends on whether, after application of de-
left in place for full 5 minutes. Diagnostic endos- congestant both the medial and lateral surfaces
copy is performed using a 30 degree nasal endo- of the middle turbinate is visible (TS1), part of
scope. If 2.7 mm scope is available it is preferred the middle turbinate is obscured by septal devi-
because it can reach the smallest crevices of the ation (TS2), or the septal deviation is completely
nose. 4mm endoscope is sufficient to examine obscures the middle turbinate (TS3). The scope is
adult nasal cavities. gently slipped medial to the middle turbinate. The
sphenoid ostium comes into view. Secretions if
The process of examination can be divided into any from the ostium is noted.
three passes:
Third pass:
1. First pass / inferior pass
2. Second pass Is the most important of all the three passes. This
3. Third pass. pass studies the crucial middle turbinate area.
The middle turbinate is evaluated for its shape
First pass: and size as well as its relationship to the lateral
nasal wall and septum. A bulge just above and
In this the endoscope is introduced along the anterior to the attachment of the middle turbinate
floor of the nasal cavity. Middle turbinate is the suggests an enlarged agger nasi cells. Sometimes
first structure to come into view. Its superior the anterior tip of the middle turbinate may be
attachment is studied. Inferior surface of the mid- triangular. This shape has no significance unless
dle turbinate is studied. As the endoscope is slid it causes obstruction to the middle meatus. A
posteriorly the adenoid tissue comes into view. middle turbinate that is concave medially rather
On the lateral surface of the nasopharynx the than laterally is considered paradoxical. But par-
pharyngeal end of eustachean tube can be iden- adoxical turbinate which is symptomatic needs
tified. Its function can be assessed by asking the to be treated. If the middle turbinate is enlarged

Prof Dr Balasubramanian Thiagarajan

due to the presence of a large air cell inside the
middle turbinate it is known as concha bullosa.
The middle turbinate is gently medialised using
its plasticity. The middle meatus comes into view.
The attachment of the uncinate process is care-
fully noted. Discharge if any from this area is also
recorded. If accessory ostium is present it comes
into view now. Accessory ostium is present more
posteriorly. Normal ostium is actually not visible
during diagnostic nasal endoscopy. Accessory
ostium is spherical in shape and oriented antero-
posteriorly, while the natural ostium of maxillary
sinus is oval in shape and oriented transversely.

Image showing endoscopic view of uncinate

process

Image showing inferior surface of inferior turbi-

nate (endoscopic view)

Image showing endoscopic view of maxillary

sinus ostium

Surgical techniques in Otolaryngology

204
Image showing sphenoid ostium

Prof Dr Balasubramanian Thiagarajan

 transversely over the skull to the opposite side.
Bicoronal approach to frontal sinus This can be curved slightly forwards at the skull
following but posterior to the hairline. The inci-
Brief Surgical Anatomy sion is often extended preauricularly to provide
access to the zygomatic arches.
The layers of the scalp include from superficial to
deep: skin, subcutaneous tissue, galea or fronta- Initially, the incision is made deep to sub-apo-
lis muscle, subgaleal fascia, and the periosteum. neurotic areolar tissue and the flap is raised along
Over the temporalis muscle, the layers of soft this plane, leaving the periosteum intact. Rarely
tissue are more complicated. Above the temporal clips are applied to the edges of the flap to aid in
line of fusion, which is at the level of the superior hemostasis. The periosteum is incised about 3 cm
orbital rim the layers include: skin, subcutaneous above the supraorbital rim and then the dissec-
tissue, temporoparietal fascia (facial nerve, and tion is carried out subperiosteally. This can be
the superficial temporal artery run in this layer), carried out until the nasoethmoid, nasofrontal
deep temporal fascia, temporalis muscle, and and fronto-zygomatic region are exposed. The
periosteum. Below the temporal line of fusion the supraorbital neurovascular bundle is freed from
layers include: skin, subcutaneous tissue, tem- the foramen by cutting them at the lower edge of
poroparietal fascia, superficial layer of the deep the foramen.
temporal fascia, temporal fat pad (middle tempo-
ral artery runs in this pad), deep layer of the deep The lateral and temporal dissection follows the
temporal fascia, temporalis muscle, periosteum. outer surface of temporal fascia up-to approx-
For males, the emphasis appropriately focuses on imately 2 cm above the zygomatic arch. At the
the status of the hairline. In some cases of mild point where the temporal fascia splits into two
male pattern baldness, the incision may be placed layers, an incision running at 45˚ upwards and
posteriorly to hide it in the remaining hair. The forward is made through the superficial layer of
patient should be aware that the incision may temporal fascia. This incision is connected ante-
become visible if hairline recession continues. It riorly with the lateral or posterior limb of supra-
must be ensured that the planned incision will orbital periosteal incision. Because the frontal
afford adequate exposure for the planned proce- branch of facial nerve courses obliquely 1.5 cms
dure. lateral to the eyebrow and not more than 2 cms
above the brow, the connection between the
Bicoronal Incision: fascia and the periosteal incisions should be at
least 2 cms lateral and 3 cms above the eyebrow.
It is an ideal incision for approach to upper one- The posterior extension of the temporal incision
third of facial skeleton and the anterior cranium. of the fascia is extended to cartilaginous auditory
This extends from one temporal region to the canal.
other and involves a major part of the scalp. For
this incision, it is recommended to shave the hair Once a plane of dissection is established deep to
for only a strip of 3-4 cms where the incision the superficial layer of temporal fascia, the dissec-
is to be made. The incision begins at the upper tion is continued inferiorly until the periosteum
attachment of the helix on one side and extended of the zygomatic arch is reached. The periosteum

Surgical techniques in Otolaryngology

206
is incised and the zygoma, frontal bone, superior
and lateral orbital margins, nasal bone and part Disadvantages
of parietal and temporal bone are exposed. When
hemicoronal incision is planned, this incision will a) Loss of hair due to injury to hair follicle in the
be stopped just short of midline. incision line
b) Poor scar in case of male type baldness
c) Inadequate access to middle third of facial
skeleton
d)Excessive haemorrhage
e) Potential for damage of temporal branch of
facial nerve resulting in weakness of frontalis
muscle.
f) Post-operative hematoma due to wide dissec-
tion of scalp
g) Sensory disturbance, anaesthesia or paresthesia
affecting supraorbital and preauricular region.
h) Trismus, ptosis and epiphora are also reported.

Various methods for hemostasis of bicoronal

incisions are

a) Use of surgical clips

b) Cautery
c) Injection of lidocaine with epinephrine
Image showing Bicoronal incision

Advantages

Maximum exposure of upper one-third of facial

skeleton and fronto-parietal region of cranium is
exposed by this incision.
This helps in management of

a) Extensive craniofacial trauma

b) Correction of craniofacial deformities
c) Single incision allows management of facial
trauma and concomitant craniotomy if indicated
d) Good cosmetic result
e) Avoids injury to facial structures Image showing intraop picture of bicoronal flap
f) Allows harvest and placement of cranial bone
grafts

Prof Dr Balasubramanian Thiagarajan

The Bicoronal flap is a well-recognized technique
for accessing mid facial region. Although the
procedure seems to be extensive, it has very less
morbidity compared to other procedures to gain
access to entire mid facial region. We have at-
tempted this article to review the indication, mer-
its and probable complications of this approach
with a brief description about anatomy and the
technique as such.

Surgical techniques in Otolaryngology

208
 cells
FESS
Aim of FESS:
Introduction:
1. Disease clearance
FESS is the acronym for Functional Endoscopic
Sinus Surgery. This procedure has revolutionized 2. Improvement of drainage
the management of sinus infections to such an
extent the hitherto commonly performed antral Instruments:
lavage has been relegated to history.
1. Nasal endoscope
Middle meatus area: This is a crucial area for the
drainage of anterior group of sinuses. Any pa- 2. Camera (endo)
thology in this area could effectively compromise
this rather critical drainage process. The success 3. Monitor
of FESS depends on how effectively this area is
cleared. 4. Surgical instruments

Stamberger’s hypothesis: Procedure: Could be performed both under local

/ G.A.
Stamberger proved that drainage from the maxil-
lary sinuses always occurred through the natural 1. Uncinectomy
ostium. He also demonstrated that the cilia of the
epithelium covering the maxillary sinus cavity 2. Bullectomy
always beat towards the natural ostium propelling
the mucous and secretions through the ostium. 3. Identification of natural ostium
He also demonstrated that a more dependent
inferior meatal antral opening had no role in this 4. Widening the natural ostium
clearance because the cilia always pushed the se-
cretions towards the natural ostium. So he found
there is no logic in performing inferior meatal Uncinectomy:
antrostomy to clear the pent up secretions.
This is the first step in all endoscopic sinus sur-
Pathology affecting middle meatus: gery. Endoscopic sinus surgery is usually per-
formed under Hypotensive general anesthesia.
1. Gross deviated nasal septum Prior to administration of anesthesia the nasal
cavity is packed with cotton pledgets dipped in a
2. Concha bullosa of middle turbinate obstructing mixture of 4% xylocaine with 1 in 100,000 adren-
the middle meatus aline. The cotton pledget should be squeezed
dry before inserting into the nasal cavity. Three
3. Infections involving the anterior ethmoidal air cotton pledgets are used for this purpose.

Prof Dr Balasubramanian Thiagarajan

 cosa to non sterile / contaminated inspired air.
One pledget is placed inside the inferior meatus,
one in the middle meatus and one inside the roof
of the nasal cavity.

Uncinectomy is the first step in middle meatal

antrostomy. Removal of uncinate opens up the
middle meatus. Open approaches to maxillary
sinus were first described in early 1700’s. The
famous procedure Caldwell - Luc surgery was
first described in US by George Walter Cald-
well and Henri Luc of France in 1893 and 1897.
Subsequent studies added to the knowledge of
physiologic drainage pattern of the maxillary
sinus which was dependent on the mucociliary
clearance mechanism led to the introduction of
Endoscopic sinus surgery.

Functional endoscopic sinus surgery is based

on the surgical approach performed by Mes-
serklinger and Wigand via the osteomeatal Image showing uncinectomy being performed
complex. FESS has become the standard surgical using a back biting forceps
treatment for chronic maxillary sinusitis. The un-
cinate process is the most important component Anatomy of Uncinate process:
of osteomeatal complex. This structure prevents
direct contact of the inspired air with the maxil- The uncinate process is a wing shaped (boomer-
lary sinus mucosal lining. It acts like a shield and ang shaped) piece of bone. It forms the first layer
plays a role in the mucociliary activity. or the lamella of the middle meatus. Anteriorly
it attaches to the posterior edge of the lacrimal
This should not be considered as a vestigial struc- bone, and inferiorly to the superior edge of the
ture, on the other hand it plays a vital role in the inferior turbinate. Superior attachment of the
ventilatory mechanisms of the nasal cavity. This uncinate process is highly variable.
thin semicircular piece of bone is considered to
be a key component of the ventilation of the nasal It may be attached to the lamina papyracea, or
cavity. This small piece of bone also serves to pro- the roof of ethmoid sinus, or sometimes to the
tect the anterior sinuses from bacteria and aller- middle turbinate. It should be pointed out that
gens by preventing the nonsterile / contaminated the configuration of the ethmoidal infundibulum
inspired air from reaching the sinus surfaces. At and its relationship to the frontal recess depends
this juncture it must be stressed that inadvertent largely on the behavior of the uncinate process.
and injudicious removal of this piece of bone
would result in greater exposure of the sinus mu- The uncinate process can be anatomically clas-

Surgical techniques in Otolaryngology

210
sified into three types depending on its superior to the ethmoidal infundibulum.
attachment. The anterior incision of the uncinate
is not clearly identifiable as it is covered with mu-
cosa which is continuous with that of the lateral
nasal wall. Sometimes a small groove is visible
over the area where the uncinate process attaches
itself to the lateral nasal wall.

Image showing type II uncinate insertion

Type II uncinate insertion

Here the uncinate process extends superiorly to

the roof of the ethmoid. The frontal sinus opens
directly into the ethmoidal infundibulum. In
Image showing Type I uncinate insertion these cases a disease in the frontal recess may
spread to involve the ethmoidal infundibulum
Type I uncinate insertion: and the maxillary sinus secondarily. Sometimes
the superior end of the uncinate process may get
In type I uncinate the process bends laterally in divided into three branches one getting attached
its upper most portion and gets inserted into the to the roof of the ethmoid, one getting attached to
lamina papyracea. The ethmoidal infundibulum the lamina papyracea, and the last getting at-
in this scenario is closed superiorly by a blind tached to the middle turbinate.
pouch known as the recessus terminalis (terminal
recess). In this type the ethmoidal infundibulum Type III uncinate insertion
and the frontal recess are separated from each
other so that the frontal recess opens into the In this type the superior end of the uncinate
middle meatus medial to the ethmoidal infundib- process turns medially to get attached to the
ulum as shown in the figure above. The opening middle turbinate. Here also the frontal sinus
of the frontal recess lie between the uncinate drains directly into the ethmoidal infundibulum.
process and the middle turbinate. Drainage and Uncinate process should be removed in all endo-
ventilation routes of the frontal sinus run medial scopic sinus surgical procedures in order to open

Prof Dr Balasubramanian Thiagarajan

up the middle meatus. In fact this is the first step
in endoscopic sinus surgery. Rarely the uncinate Surgical Procedure:
process itself may be heavily pneumatized causing
obstruction to the infundibulum. Uncinectomy which the preliminary step to mid-
dle meatal antrostomy is performed ideally under
Atelectatic uncinate process: general anesthesia. It can also be performed
under local anesthesia. The author prefers general
In this scenario the free end of the uncinate anesthesia because it causes less discomfort to the
process shows hypoplasia and gets attached to the patient and the risk of aspiration is minimal when
medial wall of orbit or to the inferior section of compared to the procedure performed under
lamina papyracea. general anesthesia. This is because 4% xylocaine
This condition is generally seen together with an which is used to anesthetize the nasal mucosa
opacified hypoplastic maxillary sinus. This sce- trickles down the throat and anesthetizes the
nario should be identified from CT images before posterior pharyngeal wall also. During surgery
surgery otherwise it would cause orbital compli- the patient will not be able to feel the secretion in
cations as the surgeon could inadvertantly enter the throat and hence swallowing reflex is blunted
into the orbit while performing uncinectomy in leading to aspiration. Some surgeons prefer to
this area. inject 0.5 ml of 2% xylocaine with adrenaline into
the lateral nasal wall over the uncinate area before
incising it. This procedure is expected to reduce
bleeding during the surgery. The author does not
infiltrate uncinate process because the threat of
bleeding is virtually non existent in hypotensive
anesthesia which is preferred for all endoscopic
sinus surgical procedures. On the other hand
inadverntant entry of xylocaine into the orbit may
cause transient medial / inferior rectus palsy.

Classic uncinectomy:

This is begun after decongesting the nasal mucosa

by packing it with 4% xylocaine with 1 in 1 lakh
units adrenaline. This decongests the nasal mu-
cosa thereby reducing the bleeding and creating
more intranasal space for the surgeon to work.
Image showing Type III uncinate insertion The incision is placed over the anterior end of the
uncinate process, which feels softer to palpation
with sickle knife when compared to the hardness
of the lacrimal bone that lies anterior. The inci-
sion can be given in either both inferior to superi-
or or from superior to inferior direction.

Surgical techniques in Otolaryngology

212
After the incision using a sickle knife the unci-
nate is medialized and removed using a Blakesley
forceps (straight one). Small tags especially the
inferior portion of the uncinate can be removed
using a 45 degree Blakesley forceps. The free edge
of the uncinate process should be grasped for
total removal. It can be removed by a medial turn
of the forceps towards the nasal septum. Removal
of uncinate process opens up the middle meatus
of the nasal cavity.

Image showing back biting forceps nibbling the

lower portion of the uncinate process

Image showing uncinate being removed using a

sickle knife

Image showing lower portion of uncinate re-

moved

Prof Dr Balasubramanian Thiagarajan

Image showing the scenario after total uncinec- Image showing middle portion of uncinate pro-
tomy. Note Bulla is visible after removing the cess being mobilized (swing door technique)
uncinate
Swing door technique:

Reverse cutting / Back biting forceps is used in

this technique. As a first step the inferior free
margin of uncinate process overlying the max-
illary ostium is cut. An incision is made in the
superior margin to form a flap from the uncinate.
The hinged uncinate (on its anterior margin)
can be moved with an elevator or ball probe. An
angled true cut forceps is used to grasp the free
edge of the uncinate process in order to remove
it. This step is followed by submucosal removal
of the horizontal process of the uncinate process
and subsequent trimming of the mucosa to fully
visualize the maxillary ostium. Once the unci-
Image showing horizontal portion of uncinate nate process is removed the natural ostium of the
process exposed maxillary sinus can easily be identified.

Surgical techniques in Otolaryngology

214
Complications:

1. Bleeding
2. Injury to orbital contents
3. Injury to lacrimal duct (seen in swing door
technique when using back biting forceps).

In order to minimize complications during un-

cinectomy the possible variations pertaining to
uncinate process should be borne in mind and
studied by CT imaging before embarking on this
procedure.

Image showing Bulla exposed after removal of

uncinate

After complete removal of uncinate process mid-

dle ethmoid group of air cells comes into view.
Largest of the middle ethmoid cells happens to be
the Bulla ethmoidalis. Next step in surgery would
be to deroof the middle ethmoid cell. Only after
Image showing widened maxillary sinus ostium removing the middle ethmoid cell will the sur-
geon be able to access the posterior ethmoidal
group of air cells.

Prof Dr Balasubramanian Thiagarajan

 While clearing the frontal recess area it should be
ensured that the mucosa surrounding the frontal
sinus ostium should be left undisturbed because
any manipulation in this area could lead to osteal
narrowing and frontal sinus drainage obstruction.

Image showing bulla deroofed

Bulla deroofing is ideally performed in its inferior

surface. It should be remembered that the lateral
wall of bulla forms the medial wall of the orbit.
Hence it should be left undisturbed. This portion
of the bone is known as lamina papyracea. Fron-
tal recess area is cleared next. Angled endoscope
(45 degrees) is ideally used to visualize this area.
Oedematous mucosa from this area should be
cleared in order to visualize the frontal recess
area. Image showing frontal sinus cavity as visualized
using a 70 degree nasal endoscope

In order to access the posterior ethmoid group of

cells the basal lamella which becomes visible after
deroofing the bulla. The structure that becomes
visible as soon as bulla is deroofed is the basal
lamella. Posterior ethmoid cells lie behind the
basal lamella. In order to reach posterior eth-
moid cells the basal lamella should be breached.
Before actually perforating the basal lamella, the
roof of the maxillary sinus is identified. Medial
and inferior portion of basal lamella is perforat-
ed with a J curette at the height of the roof of the
maxillary sinus.
Image showing the frontal recess area

Surgical techniques in Otolaryngology

216
Image showing posterior ethmoidal cells exposed Image showing basal lamella perforated
after perforating the basal lamella which is the
horizontal portion of the middle turbinate. Posterior ethmoids are dissected until the anteri-
or face of the sphenoid sinus is reached. The skull
base is identified. Further dissection will lead on
to the sphenoid sinus.

Indications for endoscopic sinus surgery

Functional endoscopic sinus surgery is common-

ly performed for inflammatory and infectious
sinus disease. Common indications for FESS
include:

1. Chronic sinusitis not responding to medical

management

2. Recurrent sinusitis

3. Nasal polyposis
Image showing J curette being used to perforate
the basal lamella in the medial and inferior 4. Antrochoanal polyp
portion.
5. Sinus mucoceles

Prof Dr Balasubramanian Thiagarajan

 significantly to nasal obstruction which could
6. Excision of tumors of nose and sinuses limit endoscopic visualization during surgery.
Such patients should be informed prior the need
7. CSF leak closure of septoplasty in conjunction with endoscopic
sinus surgery.
8. Orbital decompression
Inferior turbinate extends along the inferior lat-
9. Optic nerve decompression eral nasal wall posteriorly up to the nasopharynx.
In patients with significant allergic component
10. DCR the inferior turbinate could be boggy and oedem-
atous. These patients would benefit from inferior
11. FB removal turbinate reduction at the time of endoscopic
sinus surgery. The inferior meatus is another
12. Control of epistaxis important landmark where the nasolacrimal duct
opens. The NLD opening is located approxi-
mately 1 cm beyond the most anterior edge of the
Contraindications to Endoscopic sinus surgery inferior turbinate.

1. Intraorbital complications of acute sinusitis i.e. As the endoscope is further advanced into the
orbital abscess, frontal osteomyelitis etc. An open nasal cavity the middle turbinate becomes visi-
approach, with or without the assistance of endo- ble. This is the key landmark in endoscopic sinus
scopic vision is preferable in these cases. surgery. It has two components i.e. the vertical
component lying in the sagittal plane, running
2. After two failures of endoscopic surgery to from posterior to anterior, and a horizontal com-
manage CSF leak. ponent lying in the coronal plane, running from
medial to lateral. This horizontal component
3. Failure to manage endoscopically frontal sinus separates the middle ethmoid air cells from the
disease is an indication for open procedure. posterior ethmoids. This portion is also known as
the basal lamella. A surgeon needs to breech the
Applied anatomy basal lamella to reach the posterior ethmoid air
cells. Superiorly the middle turbinate attaches to
Immediately on entering the nasal cavity the first the skull base at the cribriform plate, hence care
structures encountered are the nasal septum and should be taken while manipulating the middle
inferior turbinate. The nasal septum is made up turbinate as it could lead to microfractures in the
of quadrangular cartilage anteriorly, this extends cribriform plate area causing CSF rhinorrhoea.
up to the perpendicular plate of ethmoid bone
posterosuperiorly and the vomer bone posteroin-
feriorly.

Recognizing deviations of nasal septum preoper-

atively is important because they could contribute

Surgical techniques in Otolaryngology

218
Image showing deviated nasal septum as viewed Image showing uncinate process
through an endoscope
Natural ostium of maxillary sinus

Uncinate process Once the uncinate process is removed, the natural

ostium of the maxillary sinus can be visualized
This is the next key structure that needs to be just posterior to the uncinate process, about one
identified in endoscopic sinus surgery. Complete third of the distance along the middle turbinate
uncinectomy is a must for successful endoscop- from its anterior edge. It lies approximately at the
ic sinus surgery. This is a L shaped bone of the level of the inferior border of the middle turbi-
lateral nasal wall and it forms the anterior border nate, superior to the inferior turbinate.
of the hiatus semilunaris (or infundibulum). The
infundibulum is the location of the osteomeatal The natural ostium is the destination for the
complex where the natural ostium of the maxil- mucociliary flow within the maxillary sinus. To
lary sinus opens. For patients with sinus disease, ensure optimal results, the surgically enlarged
a patent osteomeatal complex is critical for im- maxillary sinus antrostomy should include the
provement of symptoms. Anteriorly the uncinate natural ostium. Failure to include the maxillary
process attaches to the ethmoidal process of the sinus ostium in endoscopic surgical antrostomy
inferior turbinate. could be one of the key reasons for failure of the
surgery.

Maxillary sinus is approximately 15 ml in volume.

It is bordered superiorly by the inferior orbital
wall, medially by the lateral nasal wall and inferi-

Prof Dr Balasubramanian Thiagarajan

orly by the alveolar portion of the maxillary bone.

Image showing natural ostium of maxillary sinus Image showing suprabullar recess
indicated by curved black arrow. Bulla and mid-
dle turbinate (MT) are also marked. Ethmoid air cells

The ethmoid sinus consists of a variable number

Ethmoid bulla of air cells (7-15 in number). The most superior
border of these cells is the skull base. Supraor-
The next structure encountered is the ethmoid bital ethmoidal cells could be present. A careful
bulla which is one of the most constant of all review of CT images of the surgeon to all these
anterior ethmoid air cells. It lies just beyond the variations.
natural ostium of the maxillary sinus and forms
the posterior border of the hiatus semilunaris. Sphenoid sinus

The lateral extent of the bulla is the lamina papy- Exenteration of the posterior ethmoidal cells
racea. Superiorly, the ethmoid bulla may extend exposes the face of the sphenoid. The sphenoid
all the way up to the ethmoid roof. Sometimes sinus is the most posterior of all paranasal si-
a suprabullar recess could exist above the roof of nuses, sitting just superior to nasopharynx and
the bulla. A careful preoperative review of the just anterior and inferior to the sella turcica. The
patient’s CT scan clarifies this relationship. anterior face of the sphenoid sits approximately 7
cm from the nasal cavity opening on a 30 degree
axis from the horizontal.

Surgical techniques in Otolaryngology

220
 to grasp the free uncinate edge and to remove it.
Many important structures are related to the Instead of a sickle knife a back biting forceps can
sphenoid sinus. The internal carotid artery is typ- be used to remove the uncinate process.
ically the most posterior and medial impression
seen within the sphenoid sinus. Bone lining over
this artery could be dehiscent in some cases. Maxillary antrostomy

The optic nerve and its bony encasement produc- Once the uncinate process is removed the natural
es an anterosuperior indentation within the roof ostium will come into view. Ipsilateral eye can be
of the sphenoid sinus. In 4% of cases, the bone palpated to ensure that there is no dehiscence of
surrounding the optic nerve could be dehiscent. lamina papyracea and also to confirm the loca-
It is necessary for controlled opening of the tion of the lamina. The natural ostium is typically
sphenoid sinus, typically at its natural ostium is situated at the level of the inferior edge of the
critical for a safe surgery. middle turbinate about one third of the way back.

Location of the natural ostium of the sphenoid True cutting instrument is used to circumfer-
sinus is variable. In approximately 60% of per- entially enlarge the natural ostium. Optimal
sons, the ostium is located medial to the superior diameter of the maxillary antrostomy is not clear.
turbinate and in 40% it could be located lateral to A diameter of 1 cm would allow for adequate
the superior turbinate. outflow and for post operative monitoring in
the office. Care should be taken not to penetrate
lamina papyracea.
Endoscopic uncinectomy
Anterior ethmoidectomy
Functional endoscopic sinus surgery usually
begins with uncinectomy. If the uncinate process The ethmoid bulla is identified and opened
can be visualized without manipulation of mid- next. a J curette could be used to open the bulla
dle turbinate, uncinectomy can be performed at its inferior and medial aspect. Once the cell
directly. Otherwise, middle turbinate is gently is entered, the bony portions may be carefully
medialized, carefully using the curved portion of removed using a microdebrider or true cutting
the Freer elevator to avoid mucosal injury to the forceps. Complete resection of lateral portion
turbinate. Forceful medialization and fracture of of bulla facilitates proper visualization and dis-
the turbinate should be avoided. section posteriorly. While working laterally care
should be taken to maintain an intact lamina
Uncinectomy can be performed via an incision papyracea.
with either the sharp end of the Freer elevator or
a sickle knife. Thee incision should be placed at The rest of the anterior ethmoid cells can be un-
the most anterior portion of the uncinate process, capped with a J curette and further opened with
which is softer on palpation in comparison with a microdebrider or a true cutting forceps. Initial
the firmer lacrimal bone where the nasolacrimal use of curette usually allows for tactile sensa-
duct is located. Then a Blakesley forceps is used tion and determination of the thickness of the

Prof Dr Balasubramanian Thiagarajan

bone and also verifies proper orientation prior to skull base and the lamina. The surgeon should
further opening of cells with powered instrumen- be aware that the skull base slopes inferiorly at
tation. Care should be taken to avoid mucosal an angle of 30 degrees from anterior to posterior.
stripping, since mucosal preservation results in The skull base lies lower posteriorly than anteri-
superior postoperative outcomes. orly. This dissection is taken back to the face of
the sphenoid.
Anterior ethmoidal air cells should be cleared up
to the skull base, while exercising caution when
approaching the roof of the ethmoid. Use of
image guidance is advisable during this phase of
dissection in order to prevent penetration of skull
base.

While moving posteriorly to new air cells, the

surgeon should ideally enter inferiorly and me-
dially and then subsequently open laterally and
superiorly once the more distal anatomy can be
judged by visualization and palpation. Anterior
ethmoidectomy is complete when the basal lamel-
la of the middle turbinate is reached.

If the disease process is limited to the anterior

ethmoidal air cells and maxillary sinus, the proce-
dure could end with simple anterior ethmoidecto-
my and maxillary sinus antrostomy. If CT images Image showing horizontal lower portion of unci-
reveal significant disease in the posterior ethmoid nate overhanging the natural ostium
and sphenoid sinus then posterior dissection is
appropriate.

Posterior ethmoidectomy

This begins with perforating the basal lamella just

superior and lateral to the junction of the vertical
and horizontal segments of middle turbinate. The
L shaped strut of the middle turbinate should
be preserved in order to ensure stability of the
middle turbinate. The lateral and superior por-
tions of basal lamella may be removed using the
microdebrider. Posterior ethmoid cells can be Image showing location of sphenoid ostium
taken down keeping in mind the location of the

Surgical techniques in Otolaryngology

222
Image showing location of natural ostium after Image showing anterior ethmoidectomy com-
removal of horizontal portion of the lower unci- pleted demonstrating frontal recess, vertical and
nate process horizontal segments of middle turbinate

Uncinate completely removed showing bulla and

suprabullar recess
Image showing the location of puncture at the
junction of vertical and horizontal segments of
middle turbinate

Prof Dr Balasubramanian Thiagarajan

Image showing posterior ethmoid cell opened
Image showing anterior and posterior ethmoidal
arteries

After surgery the nasal cavity is packed with

merocel pack which is left in situ for a week.

Risks associated with FESS include:

1. Bleeding

2. Synechiae formation

3. Orbital injury

4. Diplopia

5. Orbital hematoma

Image showing posterior ethmoid cells opened 6. Blindness

and sphenoid sinus ostium becomes visible
(green circle) 7. CSF leak

8. Nasolacrimal duct injury/epiphora

Surgical techniques in Otolaryngology

224
 tions following ethmoidal sinusitis which include
External ethmoidectomy orbital cellulitis, orbital subperiosteal abscess,
orbital abscess, superior orbital fissure syndrome
Ethmoidal sinusitis is one of the most compli- and cavernous sinus thrombosis.
cated pathologies in ear / nose / throat practice.
Because of its critical location, ethmoidal sinusitis 3. Managing chronic ethmoidal sinusitis in areas
can become really dangerous and difficult con- where facilities for endoscopic sinus surgery is
dition to treat. Types of surgical interventions not available.
include:
Procedure
1. Intranasal ethmoidectomy using nasal endo-
scope This surgery is ideally performed under General
anesthesia because manipulating the globe can be
2. External ethmoidectomy uncomfortable for the patient. Incision, a curvi-
linear one about 3 cm long is made at the mid-
3. Transantral ethmoidectomy point between the medial canthus and the middle
of the anterior nasal bone. The skin is incised,
Ethmoid sinuses begin their development during and the dissection is carried down to the perios-
infancy and continue to expand during the early teum. The angular artery could come in the way
childhood. The ethmoid sinuses are paired struc- and should be transected and ligated. Dissection
tures, and are divided into anterior and posterior is carried subperiosteally to the posterior lacrimal
ethmoidal cells. The division is provided by the crest, avoiding damage to the lacrimal excretory
basal lamella of the middle turbinate. Ethmoid structures. The medial canthal tendon may need
sinuses in adults have an average length of 4.5 cm to be released, to allow an easier access to this
and a height of approximately 3 cm. area. If this is done care must be taken to reposi-
tion it correctly. The posterior crest may need to
Walls of ethmoid sinus are composed of max- be removed. Dissection can be extended supe-
illary, palatine, frontal, lacrimal and sphenoid riorly to the frontoethmoid suture as this is the
bones. Lateral to the sinus lies the lamina papyr- demarcation between the ethmoid and anterior
acea and superiorly is the fovea ethmoidalis. Ulti- cranial fossa.
mate drainage pathway for secretions from ante-
rior ethmoidal cells is the osteomeatal complex in Complications
the middle meatus. The posterior ethmoidal cells
drain into the superior meatus. 1. Cutaneous scar could lead to medial canthal
webbing, telecanthus, and medial canthal dys-
Indications for surgery topia, especially if the medial canthal tendon is
released and not properly positioned.
1. Patients who have not responded to medical
therapy for 3-6 weeks duration 2. Periorbital oedema, injury to extraocular mus-
cles with diplopia, parathesias in the distribution
2. Patients who have developed orbital complica- of the supraorbital, supratrochlear, and infrat-

Prof Dr Balasubramanian Thiagarajan

rochlear nerve distributions and blepharoptosis
can also occur.

3. Globe injury

4. Blindness can occur fro hematoma / excessive

pressure on the globe, occluding the central reti-
nal artery during the surgery.

Image showing incision for external ethmoidec-

tomy (Lynch incision).

Surgical techniques in Otolaryngology

226
 the advent of CT scan x-ray paranasal sinuses was
Endoscopic Management of Fronto ethmoidal the only diagnostic tool available. X-ray would
mucocele usually reveal the loss of normal haustrations
found in the frontal sinus. Infact it was even con-
A mucocele is an epithelium lined mucous con- sidered pathognomonic.
taining sac. It usually develops when the sinus os-
tium gets obstructed by chronic sinusitis, polyps Using a 4mm 0° nasal endoscope the surgery is
or tumors. These mucoceles are known to erode performed. The complete surgery was performed
the bone and may involve the brain and orbit. It under general anesthesia. On deroofing the agger
may also present as a forehead mass with pro- nasi cell the contents of the mucocele started to
ptosis as in this patient. Classification of Frontal extrude. The frontal sinus ostium was widened.
mucocele: When the scope was introduced through the
widened frontal ostium the posterior table of the
Frontal mucoceles have been classified into 5 frontal sinus was found to be eroded. The frontal
types depending on its extent. lobe of the brain was clearly visible. The brain
can be identified by its characteristic pulsations
Type I: In this type the mucocele is limited to the coinciding with the patient’s respiration.
frontal sinus only with or without orbital exten-
sion. Type II: Here the mucocele is found involv- The major advantages of endoscopic approach are
ing the frontal and ethmoidal sinuses with or
without orbital extension. 1. The procedure has minimal risk

Type IIIa: In this type the mucocele erodes the 2. There is no scar
posterior wall of the frontal sinus with minimal
or no intracranial involvement. 3. Intranasal drainage path can be created

Type IIIb: In this type the mucocele erodes the 4. Minimal complications
posterior wall with major intra cranial extension.

Type IV: In this type the mucocele erodes the

anterior wall of the frontal sinus.

Type Va: In this type there is erosion of both an-

terior and posterior walls of frontal sinus without
or minimal intracranial extension.

Type Vb: In this type there is erosion of both

anterior and posterior walls of frontal sinus with
a major intracranial extension. Among mucoce-
les affecting the various paranasal sinuses frontal
mucoceles are the most common (65%). Before Image showing agger nasi cell

Prof Dr Balasubramanian Thiagarajan

Contents of mucocele seen extruding after agger
nasi cell was opened

Surgical techniques in Otolaryngology

228
TESPAL (Trans nasal endoscopic sphenopala-
tine artery ligation)

History:

This procedure was first reported by Budrovich

and Saetti in 1992. This procedure can safely be
performed under GA. / L.A.

Indication:

1. Epistaxis not responding to conventional con-

servative management.

2. Posterior epistaxis

Procedure:
Image showing the position of sphenopalatine
The nose should first be adequately decongest- artery
ed topically using 4% xylocaine mixed with 1 in
50,000 units adrenaline.

A 4mm 0 degree nasal endoscope is introduced

into the nasal cavity. The posterior portion of the
middle turbinate is visualized. 2% xylocaine