Otolaryngology Update: CME in Surgical Otology and temporal bone dissection,June 27,2009 ,Vellore

Dr. Rupa Vedantam

Professor & Head

Department of ENT- Unit 3

Christian Medical College Hospital

Vellore- 632004. India.

Phone: 0416-2283483

Fax: 0416-2232035

Cadaver Dissection

The best part of being an ENT is that almost every procedure can be learnt by Cadaver Dissection. Cultivate (?bribe) some mortuary fellows, medical officers etc and dissect on fresh cadavers. If possible keep a separate portable suction etc in your vehicle along with the instruments and dissect, dissect, dissect. Then observe as many people as you can (videos, live, mini fellowships, observerships etc.) and again come back and dissect some more (applying what you've seen). And never stop dissecting. Some of the most pioneering approaches in ENT were (and indeed still are) first conceived, honed and practiced on cadavers..... Dr Yogesh Jain

Regarding Cortical mastoidectomy

Venkat Karthikeyan Chokkalingam

Regarding Cortical mastoidectomy

Surgery needs to be tailor-made for an individual patient with combination of approaches rather

than all or none cortical mastoidectomy.

Combination of approaches includes the following

1. Transcanal approach- inspecting the intactness of the ossicular chain, removal of disease from the middle ear

2. Cortical mastoidectomy should be done to address mucosal disease /granulation disease /cholesterol granuloma of the mastoid air cell system and mucosal disease from the superior part of attic, medial/superior to head of malleus and body, short process of incus in the posterior epitympanum

*I presume the figure of 98% of finding a normal mastoid comes if we start doing cortical mastoidectomy for all perforations and not when we do it for indications a. persistent , recurrent chronic otitis media with perforation, not responding to medical treatment , abnormal mucosal disease (polypoidal, edematous mucosa ) around intact ossicles, granulation disease with attic/aditus/antral block without any cholesteatoma

3. Optimal removal of the posterior canal wall and the inferior part of the lateral attic wall which is just enough to visualize and remove the mucosal disease around the ossicles and inferior part of attic to open up the air pathways (idea is to preserve the integrity of the canal wall/lateral attic wall as much as possible without disrupting the Ossicular chain).

For me it is equally important to preserve the natural integrity of superior canal wall/lateral attic wall in a tubotympanic disease with intact ossicular Chain as compared to preserving the integrity of mastoid air cell system

Dr Suri Prabu

then the surgeon must work within the narrow corridors of the following rules -

1. normal anatomy must be sought to be preserved at all times - and, if, after the the excision of pathology, there is alteration of normal anatomy - then attempt must be made to restore 'physiologic' anatomy (because the ear has a very important function - in the sense that it subserves the sense of hearing)

2. foreign particulate matter must be avoided at all costs - in the healing (surgically treated) middle ear- and the air bubble of the 'new' middle ear must be free of adhesions and fibrosis -

it should be a pliable balloon - which drives the malleus when lateral (sound) energy is applied on it

3. Gelfoam (especially the cheap forms) contribute to foreign body reactions in the middle ear - and even if the result of tympanoplasty is 100% (as evidenced by 'intact tympanic membrane) - the patient might have 'bad' hearing

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CME in Surgical Otology and temporal bone dissection,June 27,2009 ,Vellore

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Cadaver Dissection

Regarding Cortical mastoidectomy