I want to talk to you about two surgical problems
of the external auditory canal.
Now,
one of these is very common but usually
doesn't require surgery.
That's the diffuse exhaust Asus scene.
So commonly in swimmers,
it's bilateral symmetrical.
The surgery when it's necessary can be rather
difficult.
And the other problem is the is the one of the
exhaust Asus
that's isolated.
Now,
we usually call these an osteo MMA,
it's a unilateral lesion and
it invariably is surgical.
It's not common,
but it is a surgical problem.
In most cases,
it is unilateral and the surgery here can
be quite simple,
particularly simple compared to the management of diffuse
exhaust.
Oh sis,
I'm going to demonstrate these to you on slides
but also on some
videotapes from our temporal bone
surgical dissection courses.
I think you'll find it quite interesting.
Now,
this is the relatively
typical picture of diffuse exhaust doses of the
external auditory canal.
Here's the short process of the malice.
You can see a fair amount of the drum.
You have these huge cecil
exhaust osi's with some that are not
quite a cecil.
Actually,
this patient has not got enough closure of the
air canal probably to warrant surgery.
And let me talk to you just a little bit about what the
indications are for surgery.
I think it's important to stress the fact that
regardless of how these diffuse exhaust
osi's look and certainly the one I just
showed you on the slide,
uh,
probably doesn't need to have surgery.
It isn't certainly closing the ear that much.
We operate.
Not on a basis really of the way it looks,
but on the basis of the symptoms that's giving the individual.
Now,
the major symptoms are those involved
with getting water trapped deep to
the exhaust gasses or the recurrent
problem of,
of otitis external.
Uh,
the easiest way to handle these medically is to
just have the patient douche the air with
ordinary rubbing alcohol after swimming and they can
usually control the situation.
However,
if it's not controlled,
if they persist in having symptoms
intermittently,
or if your observation has led you to
believe that continual
progress of the problem you've been watching is going to in
fact,
result on closure of the ear canal,
then obviously surgery should be done.
Now,
the surgery here can be rather tricky
because the ear canal,
in fact is almost closed by the
lesion.
The major risks of complications
are to number one,
Tearing the Eardrum,
well,
that can be fixed at the time of surgery.
And I forewarn all these patients that there's at least
a 10% chance that I may have to repair the eardrum
in connection with the surgery.
The other risk and knock on wood.
I haven't had this happen to me.
I sure have had perforations from some of these.
But the other complication is the matter of sensory neural
hearing impairment.
And if you air and let the
bird touch the Malley's because these people
have intact ear drums intact are
secular chains and normal hearing.
Let me show you a little bit about the surgical
approach.
Now,
I think the biggest mistake that people make when they
encounter something like this is to treat it as a simple
problem.
Simple problem,
meaning approach it through the external auditory.
Me.
A dis that's a mistake.
That's a mistake that can lead to
perforation of the eardrum,
incomplete surgery and very
difficult exposure.
What you want to do and what I do in all
these cases is to go behind the ear.
But this will help show you what,
what the real problem is.
Let me point out here.
This is the,
here's your promontory,
here's your facial nerve,
here's the Mallia.
So this is the ear drum.
Here is the
cecil eggs,
osteoporosis on the
anterior inferior wall.
And here you have it on the posterior
superior,
you see what you've got and you've got to get down here and get
this off and you've got very little space as you'll
see from the surgical sequence.
So I like to approach them post auricular lee turn the
air forward,
make sure that your incisions come far enough forward,
both inferior and superior early
to get an adequate view of the ear canal.
Now,
what you're looking into then are these
few sex osteoporosis?
And what I do,
I take the skin,
I take the skin from the this
point all the way out,
totally out of the ear,
take a large drill and just start drilling on
this and keep drilling on it,
taking off the exhaust until you get
to the point where this starts to open up.
In other words,
once you get to about this point here,
then you switch and you start going to smaller
birds and working on the individual areas
and you actually sort of eggshell it,
you end up by having this all very s
excavated.
And once you've got it very excavated,
then you can take a cure or a diamond
stone and get off the remnant.
Now,
essentially what we've done we did was to take the
skin out of the outer half of the ear canal,
we pushed the skin of the inner half
forward of us as we worked with the
drill and in the final steps and once you get
this off,
you just lay the skin back in place.
Now,
I'm gonna show you now the first
surgical sequence.
Uh and we'll make a few comments as we
go along in the area where you can
see the eardrum is right at this area here.
Now,
the problem is how do you go about approaching this sort of case?
Well,
I'll tell you the one thing you shouldn't do in my experience
don't do them through the ear canal.
It would seem logical but it's much better to come
in from behind.
First thing I'm gonna do is to develop a
this area here that between the tempo gnome
asteroids future at this point
and the temple suture,
what it is here so that I have a little,
this little flap of skin that's normally attached to the
oracle.
Now let me have a number two knife,
I will try to cut across the base of that at
this point here,
cut across the base of it and free that up.
Okay.
Now,
that will serve as a little skin flap to
cover this area here.
Alright.
Now let me have,
let me have a beaver knife.
What I'm gonna do now is to make a circumferential
incision because I'm gonna be taken
off all of this skin and we'll make a
circumferential incision coming around
and joining up with this one right here.
Superior li then we
will complete that around.
Now,
what I'm going to do,
let me tell you as I make this incision,
what I'm going to do is to take all the skin out of the
ear until I get to
the what amounts to the area where the exhaust
doses are the most most
prominent.
And then at that point,
I will dissect the skin off of them and
elevate it towards the ear drama.
So I came in behind the ear,
made a post curricular incision.
And what I'm gonna send,
what I'm gonna do is just like I would on a chronic ear,
so to speak.
I'm gonna go ahead out of Muhlenberg one turn.
That's it.
Okay.
Now that you've seen that,
let me put in the retractor and then we'll go back to the
microscope.
Well,
I guess I'll go back to looking through it myself.
Okay.
Now,
let me have a suction for here.
Let me have the frayer.
Now,
what we're gonna do here is to elevate this into their,
here's the area of the spine of Henley,
right?
There's millennia,
temporal,
here's the spine of Henley right there,
huh?
What we want to do now,
there's the strip that we created.
Let's have a weapon.
And what I'm going to do is to roll that out
and I'll take my weapon and slip it in here
like this and sort of lift up
and lift up this way you see.
Okay,
fine.
We'll reset the retractors again and get
it under the vascular strip like this.
All right.
Now,
out of trend Ellenberger turn,
if you would,
okay.
At this point,
I'm just going to start off just like I would in a
chronic ear.
I'm gonna start taking off the canal skin.
Now,
one other,
one principle in this surgery that I think is
important is,
is get,
get adequate exposure and then don't be too
conservative with the skin.
Don't,
don't try to,
don't fiddle around and try to,
you know,
pussyfoot along because of the fact that you won't
want to take damage any of the skin.
You've got to get the exposure.
You've got to get the show on the road,
so to speak.
And at times that means sacrificing skin.
Now,
when you get down near the
eardrum,
you start going very,
very slow.
Of course,
because you don't want these people to span has normal
hearing and they invariably do.
And the a common minor
complication is tearing the
eardrum.
And I would suspect in one out of every 10 of
these,
I do,
I have to do a minor little repair of the eardrum and that doesn't
concern me,
but you don't want to touch our secular chain,
that's for sure.
Right now,
at this point,
we have started to take this off the exhaust
osi's.
You see now,
what I do at this point is to get the skin,
try to get the skin out as quickly as
possible.
I will dissect this down and roll the table towards me
a little more as far as I can conveniently do so
and then take out the outer half of the skin,
hold it,
get it down as far as I can get it this way and then
get it out of the ear.
Alright.
And getting it out of the ear means putting an instrument.
Why am I doing,
putting an instrument here and sort of a vaulting
it like this.
I don't,
I don't try to cut it gently and so forth
because I found that when I do that
too is,
is frustrate myself.
I just sort of put it down like that and pull out.
You see,
I've dissected the skin down to that point and I just put it
down and sort of
elevated,
so to speak.
Huh?
Put it down here like this in our
instrument in and then just sort of,
if we can want to get as much as we can
without spinning our wheels,
so to speak.
Now,
this is not the way I used to do when I first started
doing,
these the first one I ever did,
I'll never forget it back in about
1959
and I did it through the ear canal and I learned my lesson
there.
I had an ear drum to repair and all
sorts of problems.
It's just not adequate exposure,
just not adequate exposure
if I can get this out here.
See,
here again,
I'm,
I'm fiddling around right now.
I'm wasting time.
There's no point in trying to
two.
You can't get all the skin out the way you'd like
to in these cases.
So you just go ahead and sort of reach
in and pull it,
which is what I'm doing now.
And should have done a minute ago.
All right.
Now,
at this point,
we ought to be able to take this out.
Yeah,
let me have a couple more steps.
This is our canal skin.
Now,
we immediately go to the drill,
rolling
the water down a bit,
a little bit more.
Okay off a bit
good.
So,
we just put this in and start drilling
like this now as you drill in.
Oh,
let me have a rose and needle.
Let me show you the pattern that you watch as you drill in.
Well,
here's where one of the big exhaust osi's was.
Here's another one and here's another one.
And if you look at this pattern,
you see this is skin here,
there's a pattern and it follows a typical pattern of A
Y,
one arm of the Y is here,
one arm of the Y is there and the other one is
there and it follows that pattern.
And what you do is you keep drilling down with the center
of your drilling right at this point here,
always staying on the lower side
because you don't want to remember.
Don't forget your drum is nearer to you post eerily and
superior early than it is anterior and inferior early.
So you sort of center,
you're drilling right at this point here.
Now,
as that area of soft tissue gets
bigger opens up,
that means you're getting past your exhaust Asus.
And at that point when it starts to open up and there's
more soft tissue,
then you start working on individual
exhaust and elevating the skin in
front of you.
Alright,
let's have a drill.
Now,
I am not concerned the two areas,
the areas that concern me in terms of my drilling,
I don't want to get into the annoyed fossa
and cherry really if I can help
it and I don't want to get onto the drum or into
the,
onto the article.
So I tend to stay,
I keep my,
I tend to stay directed a little bit inferior and
interior,
but keep watching to make sure that I'm not getting
into soft tissue,
I probably will get into soft tissue.
But uh I don't want to get into it much.
Let's put it this way.
You want to recognize it when you do,
let's put it that way.
So at this point,
we're working,
you might extend some,
some extent without being able to see past where we're
working.
But we're following down that soft tissue
and knowing that and doing so that's where we're centering
things that that's the way to go.
I tell all these patients when I do these,
that first place,
I don't do them on the way they look,
do them with rare exceptions,
you do them because of symptoms.
And I tell all of them that the,
the major risk and complications
involved is tearing the drum,
which usually doesn't present much of a problem because you were
repaired immediately and the other one is getting
into our secular chain and getting into hearing loss
as a result of a sensory.
No,
that's not happened to me yet,
but I'm sure if I do enough of them,
it will someday.
This is a relatively typical one
in that the exhaust go are
continuing to go down.
We're getting nearer and nearer to the drop.
One of the things that make one of the many things that makes
these tricky operations if you haven't done them
before,
is that constant question of how near to how
did the drum am I?
You know,
you don't want to get into trouble.
Well,
there's a rule here.
Your question about it.
Always stay low and anterior.
That's the secret low and anterior.
That's where you have the most room.
Now,
let me show you something else you can do.
Let me have a number one knife.
Now,
at this point,
we're opening up a little bit and now we
can try to open up this wire area
and take a look to see how far,
let me have a number.
Let me have a number one knife.
Here's our skin.
We can start,
we can take a peek and find out how near the drum we are at
this point and then we'll push that skin back
in.
Now,
there's your drum right there.
Do you see that?
There's the drum?
Let's take a closer look at that and I want you to
look not only where the drum is but the general
angle of the drum.
If you look in here,
now we open that up and there's
your drum.
Okay.
Now,
notice that the drum goes,
if you can see the orientation,
let me get you back.
Notice that the drum in that area is in this
plane and that's the plane in which I've been
drilling,
constantly keeping the deepest area of
penetration and clearly inferior early.
So that as you go in,
you go in parallel to the drum surface
on.
Alright,
again,
I'm gonna stay anterior and inferior.
The reason being you don't want to expose
yourself up there until you've got a
better view of things because that's where you're gonna get into
obstacles and gonna get near the drum much quicker.
At this point.
I'm beginning to
let's have the next smaller size drill.
Now,
at this point,
I'm beginning to scoop out the exhaust
and leave an eggshell type of thing.
I'm not drilling on the area where their
skin is.
I'm drilling back from that so that I'm trying to egg
shell and then I can go in with a cure it and knock it off.
You see,
I realized that this is not a slide of this
patient's ear,
but I wanted to point out something when I,
we go back into this sequence,
you watch right down in this area here and I
expose the facial nerve in the ear canal
and I'll comment on it later on,
but you'll notice that because I've done this and I
realized that I started to change my
procedure bit,
working more anterior and inferior early and
being a bit more cautious than I might.
And I thought it might be a interest to you in connection with
exposing the facial,
in the ear canal to take a look at some of the drawings by Ward
Litten.
I apologize.
All the lettering is backwards,
but that's so that I can set this up as a right ear
hears the tim panic membrane and
this is the tim panic course of the facial
and the mastoi portion.
And this drawing is out of an article by Ward Litton
that appeared in the September 69
Laryngoscope as I was working down the ear
canal,
I actually got enough posterior to expose the
facial nerve at about this point here.
Now,
if we look at this in another orientation
here,
we're looking from behind forward.
Here's the tim panic membrane Angeles,
here's the facial nerve,
I exposed the facial nerve right at this point.
Here just goes to show that you can
encounter the facial anywhere in the air.
The important thing is to realize that you're there.
Here's a case where the word visualize is
quite properly used.
You've got to visualize the air drum
because you can't really see it.
Well,
you've got to visualize where it is in terms of your
working.
I'll get a little bit more vision and so forth.
No,
if it doesn't want to,
there we go.
Okay.
And we'll switch to a diamond bar.
One thing I could have done here,
but I elected not to.
I was a little,
I was a little bit surprised to find out I was this low down
here.
Therefore,
I want to explore this more.
I could have left these edges of bone
as a protection of my skin flat,
but I'm going to switch to a diamond.
So I don't really have to do that.
All right.
Take this.
Let me have the weapon again,
please.
Now we can open this up a bit more
and take a little bit more.
Look at it again.
The secret of success in these is do it
gently.
Now this these,
these really come right down on the drum.
This bone really comes down on the drum.
Now that I can see how deep I am
and where I am now,
I will go ahead push this skin back
in and we'll go ahead
with a diamond drill.
I'm gonna work with a cutting board a little bit here
superior because I've got quite a bulk of bone.
Alright.
Roll them.
All right.
Now,
let's go ahead and take a look here and see if we can at this
point.
See AMBO is what I'd like to be able to
identify.
Alright,
Dumbo is gonna be in here.
We're posterior to it.
Okay.
We're right now.
We are right at the annular ligament here after we
get this bone off and I'm gonna leave that bone now as
a protection and we'll go ahead and work up here.
We're still way posterior
apparently.
All right
off.
Let's have the next smaller sized bird
at this point.
As you see,
I've identified the drum and I know my direction
at this point.
I'm sort of keeping an eye on how thin the bone is
getting.
Plus seeing if I get to
the bone,
it looks like the annular,
bony annular,
but I'm drilling inside this shelf,
keeping it thinning it down as I go
and it is protecting me from the eardrum
question that's often asked in these,
well,
with all this and taking all the skin out,
how often do you get a stenosis,
do you know,
knock on wood?
I've not had one with this.
I think that that's unusual in my experience
here is the way I've done them for years
and I'm not aware of having one.
I suspect somebody else has seen one or two of mine,
maybe if I had any,
but I haven't seen him.
They just seem to do beautifully.
They end up by being covered with skin
for the most far.
All right.
Now,
let me have the stay peas,
cure it and we'll take off some more of the bone here
and flip it off.
It looks relatively thin
like this.
Huh.
Put it in trying to get it off.
Leaving the skin behind
like this.
Her,
let me have a forceps.
No,
don't
in all these maneuvers I'm doing now where I'm
slipping an instrument in.
You've got to be careful not to put pressure down on
the drum.
You slip it in,
but be careful when you do that you don't.
And when you go to curate the bone off,
I'm prying it off like this.
I'm not doing this with it because you
could easily touch the
obstacles and get into trouble.
So I'm actually putting it in here and using it as a
lever.
Do you see like that?
There we go.
It's fun operation.
It's kind of tricky,
but it's kind of fun to do because it's different,
you know,
new and different type of thing.
See,
here's a case where you have to be very careful
obstacles,
short processes.
That's bone of obstacle right there.
And you gotta be very careful not to pry on it.
So you can't do the curating the way you
would normally do it.
That's what I'm doing is not the way you normally cure it.
You don't use a scraping motion,
but that's what you're doing here.
All right.
Now,
let me have the,
let me have a number one knife.
We're making good progress here.
Now,
you can begin to see the drum
and there's the um bow right there.
See,
okay,
at this point,
we can begin to see how much more we've got to
do.
You want to get it all off,
within limits weapons?
You don't want to get it all off to the point that when you've
finished it you've torn the drum.
Well,
let's see how much more we have to go here.
Well,
we've got a fair amount.
You see that fair amount to go there.
Okay.
Roll them,
turn the water down a bit.
I have to stay,
please.
You'll notice I've still left some bone up in there.
That's again,
just so that I don't get into that area too
closely until I really plan on it.
In other words,
I don't want to get into it by accident.
So I like to go with this slow and easy,
methodically and so forth and just take your
time because you can really,
you can really get into trouble with these and have a real
mess on your hands.
If you start,
if you know,
if,
if you're not very careful with them,
they are not easy to do
another message to that is don't go doing them unless they need
to be done because these are the interesting thing about these
patients is as opposed to almost other,
almost any other ear surgery you do.
These patients don't have any trouble,
they don't have any hearing loss,
they don't have a draining ear.
All they have is an ear.
That looks odd.
So you want to make sure they've got trouble,
the warrants doing something and that trouble is
usually recurrent episodes of Otitis external.
I do keep an eye on some of these and if I've watched
them and it's obvious they're getting worse and worse and
worse,
even though they haven't started to have symptoms,
but it's obvious weapon that they are going to have to have it
done,
then it's a little bit easier to do it before it blocks it this
much.
But nonetheless,
you don't want to get too eager with these.
They are,
they are cases which are
fraught with all sorts of difficulties.
I've got a little hematomas on the eardrum.
Things are looking pretty good here.
Inferior.
Well,
we've still got a ledge,
huh?
All right.
Roll the table away some more.
Would you
let me have the staples,
cure it again,
please?
I can use a fairly good sized Keret here because
I'm away from the,
um,
bow in our secular chain.
And at this point I'm fairly safe.
It's fairly safe to do.
So.
I mean,
you can do all this work with a drill,
but I guess this just shows my antiquity.
I learned to use a cure it many years ago
in training and I like to do it.
Let's have the weapon again,
please.
Uh,
we're at the annular ligament right now.
No,
Dr.
Christian will be closing within 15
minutes.
All right,
we are at the annular ligament there.
We still got a little bone that might be taken off at
that point.
But let's see now.
Heck no,
you see,
you can see annular ligament already.
You see,
you can see the annual list right there.
Let me show you something here.
Something I was just analyzing.
I think I've got facial nerve exposed in the ear canal.
Let me take a look and see if I do.
It could be.
I saw it when I came on it right here.
Do you see this?
That's facial might as well pointed out
to you because you don't often see this.
Let me have a,
let me point out what I did.
You remember I said that as I was coming in,
I was coming in a little far back here.
Where do you see that white?
That's facial nerve shows you can get to the
facial nerve in the ear canal.
You don't see that very often because you don't normally approach
away.
But that's facial nerve and it shows that the
facial which is up would normally be lying medial to
the medial ligament up here is now riding lateral to it on the
course to the style mastoi.
Huh?
Okay.
We're down to annular ligament there.
We've got a bit up here.
Not a lot.
Let me have a cutting bird next to
the uh medium.
Now,
what I'm gonna do is I'm gonna use a cutting burr
lateral to the next smaller
size.
You see the apex,
the apex of this bone right here.
Right where I'm touching,
I'm gonna use,
I'm gonna work lateral to that.
And that way I know I'm lateral to hospitals and I'm going to thin it
down with a cutting burr.
Both on.
We're just going to thin this down with a cutting bird
and create sort of a shell.
The shelf turned the water down just a bit.
The shell protects us from the articles from the
skin,
from the eardrum.
You see,
the shelf is getting very thin.
In fact,
it's almost cut through at this point.
Now,
let's have a staple cure right now.
We'll take that off like this,
huh?
Okay.
Art.
So at that point that leaves us with a little bit,
we can take off here with the cure and you
can oftentimes finish it in this portion up here.
Now,
this is the difficult angle to get done is this
anterior superior angle.
But whereas in our tim panic membrane drafting,
it's important.
It's not here because it's all going to be covered by skin.
You see now,
at this point,
we can also come back here and take off some of
this right next to the
All right.
Now,
let me have now a weapon as I think we're near to the
point where we're gonna be through here.
Let's just take a look,
fold our skin back up,
see where we stand how much we got left
unfold the skin like this.
Now there's,
there's swelling over the drum and I can't see the
short process,
but I can feel short processes right there.
We are above the short process.
All right.
Now,
what have we got here?
Well,
we got a little overhang up here,
but this is almost cosmetic from this point on.
I'm gonna just take a little of this off to make it look
pretty.
I'm gonna cut this flat down to about the
level of the annual.
It's just so that it will lie flat like that.
Otherwise it would hang up a bit.
You see?
All right,
let me have,
let me have the weapon.
That attorney.
Okay.
Well,
Jerry,
I think we are ready to have some packing right
now.
Drum looks good.
Now you can tell that there's no hole in the drum because the drum is
bulging because of his anesthesia.
She just balls right out.
You see it.
And uh,
so that's very helpful.
Normally the anesthesiology is not very helpful in these
cases,
but he sure is here.
Let's have more and bigger.
Now let me have the other canal skin.
It doesn't look very good,
but it's alright.
Let's have a ring.
Well,
I usually advance it in a bit.
Normally I don't,
normally you're missing an area and I
leave a little royal external.
Yeah,
between it and the other skin and so forth.
Try to make sure the skin edges are rolled
out.
All right.
Let's have packing.
Okay.
Roll.
That's fine.
That's good.
I didn't,
I didn't show putting the vascular strip back in place,
but essentially what I did,
I put all the skin back in place and then put the vascular
strip back in place,
packed the ear with gel foam,
uh with gel foam soaked with some quarter
spore in solution.
And the postoperative care is to leave all this
alone for about 10 days.
Then you can aspirated in the office.
And if the year has any drainage problem,
which it sometimes does with granule ations,
I put them on dilute vinegar,
swishes,
half strength white vinegar.
Let me show you a little bit about this matter of the osteo um of the
ear canal.
This is what it looks like.
Notice that it's normally attached at
the junction of the outer and middle third of the year
canal and it presents itself just in this way
and uh the treatment of its
relatively simple.
Now,
there have been a number of different ways that have been recommended at
times to approach problems of the ear canal.
I don't recommend any of these for the most
part.
But here is one that fact,
in fact depicts what you do.
You don't do it in the office or with a patient standing up,
but you take a little mallet and
gouge and you tap it and it falls
off the way you can do that
is this here shows you a view,
you're looking into the air canal,
you have this podunk,
yah,
lated unilateral osteo MMA
attached to the Timpano squamous suture.
What you normally do working through the air
canal,
usually under local anesthesia.
You can pass a hook down deep to this,
take a little gouge,
have your nurse tap it and the thing falls off
and you can deliver it out the ear easily.
You may want to take a little burr and burnish the base of it.
Now,
this is not what I'm going to show
you on the tape
because unfortunately,
I didn't have a tape of this.
But I have a very unusual case.
This is of a doctor and he had a
solitary osteo more of his ear canal,
but it was attached right next to the short
process of the malia's.
And on him,
I went in behind the ear doing this post to
regularly under local.
But I used the same technique finally to get it out.
I passed something deep to it.
I then put a gouge here at this point
anyway,
tapped it.
And as you'll see,
the osteo MMA fell away very
nicely.
Let's go to the T V tape.
This,
this patient has a solitary
osteo Mahy in his left ear canal.
And he's been under the observation of an ear,
nose and throat man for oh 10 years or
so and his ear gets plugged up occasionally and he's been
watching the things slowly grow and referred him to me.
He's got mild diffuse exhaust.
Oh sis in both ears canal,
both ear canals.
This is no problem.
This is a solitary osteopath.
The only thing different about it is that solitary osteo Mazar
normally unilateral as this is the
only thing different about it is that they're normally in
the,
at the junction of the outer and middle third and they're usually
attached to the temple suture line.
This one is quite a bit further immediately than this.
And whereas I might normally go through the ear canal
here,
I have gone post irregularly.
Now,
prior to the time we started the tape,
I made a post auricular incision,
turned the air forward,
transected the ear canal and now we'll go to the
microscope and take a look.
Now,
I realize I've transected the ear canal at about the
junction of the outer and
middle third.
And this is way down in deep frozen
needle,
way down in deep.
You can just barely see around it,
but it's quite a bit different in that.
They are normally attached out here at this level and you can
easily do them trans canal.
Now,
this is not,
And the question only.
So I went post directly on it so that I could get a
better view of it,
but it's about three quarters,
90% blocked.
So what I'm doing at this point is cutting out the
vascular strip area.
Now,
one could say,
well,
why didn't you leave it attached to the oracle?
Well,
I didn't because I didn't think it was gonna be
necessary and it's a very little
concern but I didn't and we'll excise
the skin and then just put it back in when we get
through.
Now,
let me have the,
let me have a weapon,
please.
But Sammy,
you can see this.
It's not a very common place to have one of these.
Usually if you see them,
they're not very common.
They're,
they're right down there in the outer,
there's much more lateral than this
white players.
Now,
what I'm gonna do let me have a two knife.
We're gonna try to cut across the base of this so that
we can take this out and not a vault it
and you can put this aside just as you would canal
skin,
Jerry,
I get the impression that if I can get it
loose,
I can get it out.
Now,
I've passed medial to it here,
but I'm not sure I can't feel myself getting
around it.
So we're gonna drill,
I'm under it here,
but I'm not under a tail.
And as I said to you all this is exactly the reason that
I wasn't gonna try to approach this from
through the ear canal because I just did not want to get
caught short on something.
What I'm gonna do,
I'm gonna take out the skin.
Let's have a # two knife.
I'm gonna take out the skin post eerily down to the
level of the lesion and
then I'm gonna drill down some of the bone post clearly to
see if I can get some room there so I can see
around it because right now
I can't see around it.
Let me have a cup forceps.
Alright.
You can put this in with the canal skin,
roll them,
turn the water down a bit,
please.
A little bit more.
That,
that's good right here.
All right off.
Let's go to the next smaller size bird.
Let's have the next smaller size bird.
And hopefully I will keep it from coming loose because
I don't little more water.
I can keep it from coming loose water.
There we go.
Turn it down a bit.
Keep it from turning down a bit.
There we go.
Keep it from coming loose because if it does,
why it will tend to impact immediately.
But I did and they didn't remark on it to you
doctor.
I went down below it and hooked under it to see if I
could move it and it seems pretty solid.
Next,
the next smaller size cutting burr.
Alright.
Roll them.
Now,
at this point with this delicate bird,
I'm actually drilling right at the junction of the two
because the reason is because I've got into a master
cell there And I just assume
not getting more to one.
Alright.
Off.
Let's see.
We'll put this down here like this.
See,
well,
we can get that out from posterior.
Really.
We can pass around the lesion
and it comes out posterior Lee.
Oh,
I think we're ready to go here now.
I think we're ready to go roll the table away a bit.
Please.
Let's get out the small gouge.
Hold it.
Now,
what I'm gonna do is to pass my hockey stick
Deep to the lesion.
Let me have a number three Baron deep to the
lesion.
Get behind it and then just try to tap it loose and
roll it out.
As long as I would feel that it's not going to
impact.
You see,
we pass around the lesion and get under it.
All right,
it's under it.
Now,
now let me have the gouge in
my left hand
just a minute.
Okay.
Again.
Again,
hold it
again again,
hold it.
That moved it,
that moved it up.
It's movable.
I may have to drill on that pete uncle.
Let's see.
I'm gonna see if I now here it comes,
it's loose.
See it coming.
Okay.
Okay.
It's loose.
Here it comes.
Okay.
Let me have the hockey stick again.
Okay.
And now we can see the eardrum for the first time
down this little hole.
That's a good sized one.
Okay.
Let me have a forceps.
Well,
no wonder it had quite a broad attachment.
Look at that.
You see that,
that's a tremendously broad attachment all along
the suture line.
Well,
I'm happy to say that this doctor
who had this very unusual osteo my,
I've never seen anything like it.
He got along very nicely.
One thing I didn't show you on the tape because it was of no great
importance was that he got a little tear in
the parts flash because of the skin of the osteo.
MMA was actually attached very tightly.
I repaired this with a small under surface graft.
Everything went along very nicely.
I packed his ear with gel foam,
took the gel phone out after about two weeks
and the ear healed very nicely.
So we've talked about two surgical problems.
One of them very uncommon,
the isolated yoma attached to the
temple,
the junction of the outer and middle third of the ear canal,
not specifically like the one you just saw,
this is invariably a surgical problem.
The other one is very common problem.
Often in swimmers,
many of my patients are professional lifeguards.
Uh the problem of diffuse
exhaust.
Oh sis which is bilaterally symmetrical usually
does not require surgery unless the
patient is having considerable symptom.
Atala ji from it and it
can be a difficult operation.
Thanks for watching.