WEBVTT 00:00.000 --> 00:30.000 position:50% align:top line:0% *This machine-generated transcript may have errors. If remediation or a manually-generated transcript is needed, please contact NLM Support at https://support.nlm.nih.gov.* 00:30.160 --> 00:33.150 I want to talk to you about two surgical problems 00:33.150 --> 00:34.850 of the external auditory canal. 00:35.350 --> 00:35.730 Now, 00:35.740 --> 00:38.580 one of these is very common but usually 00:38.580 --> 00:39.910 doesn't require surgery. 00:39.970 --> 00:42.350 That's the diffuse exhaust Asus scene. 00:42.350 --> 00:43.960 So commonly in swimmers, 00:45.160 --> 00:47.150 it's bilateral symmetrical. 00:48.350 --> 00:50.820 The surgery when it's necessary can be rather 00:50.820 --> 00:51.430 difficult. 00:52.920 --> 00:55.440 And the other problem is the is the one of the 00:55.440 --> 00:56.740 exhaust Asus 00:59.020 --> 00:59.990 that's isolated. 00:59.990 --> 01:00.130 Now, 01:00.130 --> 01:02.180 we usually call these an osteo MMA, 01:02.220 --> 01:05.140 it's a unilateral lesion and 01:05.150 --> 01:07.440 it invariably is surgical. 01:07.450 --> 01:08.440 It's not common, 01:08.890 --> 01:10.470 but it is a surgical problem. 01:10.570 --> 01:11.560 In most cases, 01:12.480 --> 01:15.360 it is unilateral and the surgery here can 01:15.360 --> 01:16.450 be quite simple, 01:16.900 --> 01:19.880 particularly simple compared to the management of diffuse 01:19.880 --> 01:20.430 exhaust. 01:20.430 --> 01:20.950 Oh sis, 01:22.170 --> 01:25.110 I'm going to demonstrate these to you on slides 01:25.120 --> 01:26.900 but also on some 01:26.910 --> 01:29.650 videotapes from our temporal bone 01:29.650 --> 01:31.350 surgical dissection courses. 01:31.720 --> 01:33.560 I think you'll find it quite interesting. 01:34.280 --> 01:34.480 Now, 01:34.480 --> 01:37.100 this is the relatively 01:37.100 --> 01:39.860 typical picture of diffuse exhaust doses of the 01:39.860 --> 01:41.280 external auditory canal. 01:41.290 --> 01:43.970 Here's the short process of the malice. 01:43.970 --> 01:45.930 You can see a fair amount of the drum. 01:46.640 --> 01:49.550 You have these huge cecil 01:49.550 --> 01:52.490 exhaust osi's with some that are not 01:52.500 --> 01:53.620 quite a cecil. 01:54.060 --> 01:55.100 Actually, 01:56.120 --> 01:59.090 this patient has not got enough closure of the 01:59.090 --> 02:01.550 air canal probably to warrant surgery. 02:01.830 --> 02:04.470 And let me talk to you just a little bit about what the 02:04.470 --> 02:06.260 indications are for surgery. 02:07.060 --> 02:09.490 I think it's important to stress the fact that 02:09.490 --> 02:12.270 regardless of how these diffuse exhaust 02:12.270 --> 02:15.000 osi's look and certainly the one I just 02:15.000 --> 02:16.360 showed you on the slide, 02:16.370 --> 02:16.900 uh, 02:16.910 --> 02:19.360 probably doesn't need to have surgery. 02:20.120 --> 02:22.950 It isn't certainly closing the ear that much. 02:23.130 --> 02:23.980 We operate. 02:23.990 --> 02:26.740 Not on a basis really of the way it looks, 02:26.750 --> 02:29.600 but on the basis of the symptoms that's giving the individual. 02:30.170 --> 02:30.280 Now, 02:30.280 --> 02:32.780 the major symptoms are those involved 02:32.780 --> 02:35.740 with getting water trapped deep to 02:35.740 --> 02:38.410 the exhaust gasses or the recurrent 02:38.410 --> 02:39.030 problem of, 02:39.040 --> 02:40.790 of otitis external. 02:41.640 --> 02:42.240 Uh, 02:43.010 --> 02:45.830 the easiest way to handle these medically is to 02:45.830 --> 02:48.420 just have the patient douche the air with 02:48.430 --> 02:51.420 ordinary rubbing alcohol after swimming and they can 02:51.420 --> 02:53.120 usually control the situation. 02:53.130 --> 02:53.840 However, 02:54.110 --> 02:55.460 if it's not controlled, 02:55.460 --> 02:57.480 if they persist in having symptoms 02:57.820 --> 02:58.790 intermittently, 02:59.440 --> 03:02.440 or if your observation has led you to 03:02.440 --> 03:04.910 believe that continual 03:04.910 --> 03:07.650 progress of the problem you've been watching is going to in 03:07.650 --> 03:07.980 fact, 03:07.980 --> 03:09.890 result on closure of the ear canal, 03:10.310 --> 03:12.350 then obviously surgery should be done. 03:12.710 --> 03:13.140 Now, 03:13.670 --> 03:16.500 the surgery here can be rather tricky 03:16.510 --> 03:17.850 because the ear canal, 03:17.850 --> 03:20.460 in fact is almost closed by the 03:20.460 --> 03:21.010 lesion. 03:21.650 --> 03:24.640 The major risks of complications 03:24.650 --> 03:26.290 are to number one, 03:27.180 --> 03:28.340 Tearing the Eardrum, 03:28.350 --> 03:28.630 well, 03:28.630 --> 03:30.730 that can be fixed at the time of surgery. 03:30.740 --> 03:33.730 And I forewarn all these patients that there's at least 03:33.730 --> 03:36.640 a 10% chance that I may have to repair the eardrum 03:36.640 --> 03:37.980 in connection with the surgery. 03:38.620 --> 03:41.250 The other risk and knock on wood. 03:41.250 --> 03:43.210 I haven't had this happen to me. 03:43.820 --> 03:46.330 I sure have had perforations from some of these. 03:46.650 --> 03:49.580 But the other complication is the matter of sensory neural 03:49.580 --> 03:50.410 hearing impairment. 03:50.410 --> 03:53.370 And if you air and let the 03:53.370 --> 03:56.000 bird touch the Malley's because these people 03:56.000 --> 03:58.820 have intact ear drums intact are 03:58.820 --> 04:01.200 secular chains and normal hearing. 04:03.140 --> 04:05.810 Let me show you a little bit about the surgical 04:05.810 --> 04:06.440 approach. 04:06.980 --> 04:07.180 Now, 04:07.180 --> 04:09.790 I think the biggest mistake that people make when they 04:09.790 --> 04:12.570 encounter something like this is to treat it as a simple 04:12.570 --> 04:13.210 problem. 04:13.950 --> 04:14.890 Simple problem, 04:14.890 --> 04:17.740 meaning approach it through the external auditory. 04:17.740 --> 04:17.940 Me. 04:17.940 --> 04:19.550 A dis that's a mistake. 04:20.030 --> 04:22.550 That's a mistake that can lead to 04:22.560 --> 04:24.140 perforation of the eardrum, 04:24.140 --> 04:26.640 incomplete surgery and very 04:26.640 --> 04:27.770 difficult exposure. 04:27.770 --> 04:30.730 What you want to do and what I do in all 04:30.730 --> 04:32.840 these cases is to go behind the ear. 04:32.840 --> 04:34.530 But this will help show you what, 04:34.530 --> 04:35.560 what the real problem is. 04:35.560 --> 04:36.570 Let me point out here. 04:36.710 --> 04:37.250 This is the, 04:37.260 --> 04:38.780 here's your promontory, 04:40.140 --> 04:41.460 here's your facial nerve, 04:42.150 --> 04:43.190 here's the Mallia. 04:43.190 --> 04:45.270 So this is the ear drum. 04:46.360 --> 04:47.950 Here is the 04:48.550 --> 04:49.780 cecil eggs, 04:49.780 --> 04:52.760 osteoporosis on the 04:52.770 --> 04:54.760 anterior inferior wall. 04:55.000 --> 04:57.690 And here you have it on the posterior 04:57.690 --> 04:58.100 superior, 04:58.410 --> 05:01.260 you see what you've got and you've got to get down here and get 05:01.270 --> 05:04.160 this off and you've got very little space as you'll 05:04.160 --> 05:05.930 see from the surgical sequence. 05:06.460 --> 05:09.350 So I like to approach them post auricular lee turn the 05:09.350 --> 05:09.990 air forward, 05:09.990 --> 05:12.630 make sure that your incisions come far enough forward, 05:12.630 --> 05:15.320 both inferior and superior early 05:15.510 --> 05:17.790 to get an adequate view of the ear canal. 05:18.740 --> 05:19.130 Now, 05:19.130 --> 05:21.460 what you're looking into then are these 05:22.040 --> 05:23.510 few sex osteoporosis? 05:23.510 --> 05:24.380 And what I do, 05:24.390 --> 05:25.610 I take the skin, 05:26.060 --> 05:28.860 I take the skin from the this 05:28.860 --> 05:30.510 point all the way out, 05:31.640 --> 05:32.980 totally out of the ear, 05:33.300 --> 05:36.070 take a large drill and just start drilling on 05:36.070 --> 05:38.770 this and keep drilling on it, 05:38.930 --> 05:41.900 taking off the exhaust until you get 05:41.900 --> 05:44.170 to the point where this starts to open up. 05:44.170 --> 05:44.630 In other words, 05:44.630 --> 05:46.640 once you get to about this point here, 05:46.810 --> 05:49.360 then you switch and you start going to smaller 05:49.360 --> 05:52.220 birds and working on the individual areas 05:52.520 --> 05:54.740 and you actually sort of eggshell it, 05:54.820 --> 05:57.380 you end up by having this all very s 05:57.390 --> 05:58.340 excavated. 05:58.540 --> 06:01.020 And once you've got it very excavated, 06:01.280 --> 06:04.250 then you can take a cure or a diamond 06:04.250 --> 06:06.200 stone and get off the remnant. 06:06.540 --> 06:06.720 Now, 06:06.720 --> 06:09.540 essentially what we've done we did was to take the 06:09.540 --> 06:12.260 skin out of the outer half of the ear canal, 06:12.690 --> 06:15.200 we pushed the skin of the inner half 06:15.200 --> 06:17.780 forward of us as we worked with the 06:17.780 --> 06:20.770 drill and in the final steps and once you get 06:20.780 --> 06:21.280 this off, 06:21.280 --> 06:23.340 you just lay the skin back in place. 06:24.170 --> 06:24.620 Now, 06:25.720 --> 06:28.560 I'm gonna show you now the first 06:28.570 --> 06:30.010 surgical sequence. 06:30.120 --> 06:33.090 Uh and we'll make a few comments as we 06:33.090 --> 06:36.030 go along in the area where you can 06:36.030 --> 06:38.720 see the eardrum is right at this area here. 06:38.980 --> 06:39.370 Now, 06:39.380 --> 06:42.260 the problem is how do you go about approaching this sort of case? 06:42.260 --> 06:42.420 Well, 06:42.420 --> 06:45.270 I'll tell you the one thing you shouldn't do in my experience 06:45.280 --> 06:47.420 don't do them through the ear canal. 06:47.420 --> 06:50.340 It would seem logical but it's much better to come 06:50.340 --> 06:51.110 in from behind. 06:51.110 --> 06:53.960 First thing I'm gonna do is to develop a 06:55.190 --> 06:57.630 this area here that between the tempo gnome 06:57.630 --> 06:59.630 asteroids future at this point 07:02.570 --> 07:04.300 and the temple suture, 07:04.300 --> 07:06.110 what it is here so that I have a little, 07:06.330 --> 07:09.070 this little flap of skin that's normally attached to the 07:09.070 --> 07:09.630 oracle. 07:10.300 --> 07:11.950 Now let me have a number two knife, 07:13.360 --> 07:16.230 I will try to cut across the base of that at 07:16.240 --> 07:17.420 this point here, 07:18.750 --> 07:21.720 cut across the base of it and free that up. 07:23.930 --> 07:24.620 Okay. 07:25.770 --> 07:25.920 Now, 07:25.920 --> 07:28.720 that will serve as a little skin flap to 07:28.730 --> 07:29.980 cover this area here. 07:29.980 --> 07:30.290 Alright. 07:30.290 --> 07:31.490 Now let me have, 07:33.790 --> 07:35.940 let me have a beaver knife. 07:35.940 --> 07:38.870 What I'm gonna do now is to make a circumferential 07:38.870 --> 07:41.790 incision because I'm gonna be taken 07:41.790 --> 07:44.170 off all of this skin and we'll make a 07:44.170 --> 07:47.170 circumferential incision coming around 07:47.900 --> 07:50.350 and joining up with this one right here. 07:51.130 --> 07:53.880 Superior li then we 07:53.880 --> 07:55.850 will complete that around. 07:55.850 --> 07:56.110 Now, 07:56.110 --> 07:57.130 what I'm going to do, 07:57.130 --> 07:59.190 let me tell you as I make this incision, 07:59.190 --> 08:01.930 what I'm going to do is to take all the skin out of the 08:01.930 --> 08:04.690 ear until I get to 08:04.690 --> 08:07.500 the what amounts to the area where the exhaust 08:07.530 --> 08:10.000 doses are the most most 08:10.000 --> 08:10.660 prominent. 08:11.330 --> 08:12.480 And then at that point, 08:12.520 --> 08:15.380 I will dissect the skin off of them and 08:15.380 --> 08:17.090 elevate it towards the ear drama. 08:17.100 --> 08:19.070 So I came in behind the ear, 08:19.080 --> 08:21.090 made a post curricular incision. 08:22.020 --> 08:23.100 And what I'm gonna send, 08:23.100 --> 08:25.690 what I'm gonna do is just like I would on a chronic ear, 08:25.690 --> 08:26.500 so to speak. 08:26.500 --> 08:29.180 I'm gonna go ahead out of Muhlenberg one turn. 08:29.830 --> 08:31.500 That's it. 08:31.510 --> 08:31.950 Okay. 08:31.950 --> 08:33.020 Now that you've seen that, 08:33.020 --> 08:35.560 let me put in the retractor and then we'll go back to the 08:35.560 --> 08:36.990 microscope. 08:37.100 --> 08:37.600 Well, 08:37.600 --> 08:40.300 I guess I'll go back to looking through it myself. 08:40.310 --> 08:41.290 Okay. 08:42.450 --> 08:43.040 Now, 08:45.590 --> 08:47.170 let me have a suction for here. 08:47.180 --> 08:48.980 Let me have the frayer. 08:50.750 --> 08:51.010 Now, 08:51.010 --> 08:53.830 what we're gonna do here is to elevate this into their, 08:53.830 --> 08:56.060 here's the area of the spine of Henley, 08:56.060 --> 08:56.370 right? 08:56.380 --> 08:57.200 There's millennia, 08:57.200 --> 08:57.870 temporal, 08:58.600 --> 09:00.740 here's the spine of Henley right there, 09:00.740 --> 09:01.140 huh? 09:02.470 --> 09:03.560 What we want to do now, 09:03.560 --> 09:05.320 there's the strip that we created. 09:05.320 --> 09:06.220 Let's have a weapon. 09:06.220 --> 09:08.580 And what I'm going to do is to roll that out 09:09.640 --> 09:12.540 and I'll take my weapon and slip it in here 09:12.540 --> 09:14.350 like this and sort of lift up 09:15.380 --> 09:17.300 and lift up this way you see. 09:17.310 --> 09:17.990 Okay, 09:18.000 --> 09:18.470 fine. 09:18.480 --> 09:21.470 We'll reset the retractors again and get 09:21.470 --> 09:23.650 it under the vascular strip like this. 09:23.650 --> 09:24.060 All right. 09:24.060 --> 09:24.300 Now, 09:24.300 --> 09:25.730 out of trend Ellenberger turn, 09:25.730 --> 09:26.400 if you would, 09:26.940 --> 09:27.400 okay. 09:27.400 --> 09:28.090 At this point, 09:28.090 --> 09:30.790 I'm just going to start off just like I would in a 09:30.790 --> 09:31.520 chronic ear. 09:31.520 --> 09:34.070 I'm gonna start taking off the canal skin. 09:35.150 --> 09:35.340 Now, 09:35.340 --> 09:35.800 one other, 09:35.800 --> 09:38.410 one principle in this surgery that I think is 09:38.410 --> 09:39.440 important is, 09:39.450 --> 09:40.710 is get, 09:40.720 --> 09:43.500 get adequate exposure and then don't be too 09:43.500 --> 09:44.890 conservative with the skin. 09:44.890 --> 09:45.240 Don't, 09:45.250 --> 09:46.130 don't try to, 09:46.460 --> 09:48.870 don't fiddle around and try to, 09:48.880 --> 09:49.760 you know, 09:49.780 --> 09:52.700 pussyfoot along because of the fact that you won't 09:52.700 --> 09:54.910 want to take damage any of the skin. 09:54.910 --> 09:56.430 You've got to get the exposure. 09:56.430 --> 09:58.270 You've got to get the show on the road, 09:58.270 --> 09:59.570 so to speak. 09:59.690 --> 10:02.340 And at times that means sacrificing skin. 10:02.340 --> 10:02.510 Now, 10:02.510 --> 10:05.310 when you get down near the 10:05.310 --> 10:05.830 eardrum, 10:05.830 --> 10:07.290 you start going very, 10:07.290 --> 10:08.080 very slow. 10:08.080 --> 10:08.610 Of course, 10:08.610 --> 10:11.320 because you don't want these people to span has normal 10:11.320 --> 10:13.140 hearing and they invariably do. 10:13.140 --> 10:15.700 And the a common minor 10:15.700 --> 10:18.640 complication is tearing the 10:18.640 --> 10:19.120 eardrum. 10:20.000 --> 10:22.980 And I would suspect in one out of every 10 of 10:22.980 --> 10:23.270 these, 10:23.270 --> 10:23.770 I do, 10:23.770 --> 10:26.720 I have to do a minor little repair of the eardrum and that doesn't 10:26.720 --> 10:27.470 concern me, 10:27.470 --> 10:29.590 but you don't want to touch our secular chain, 10:29.590 --> 10:30.570 that's for sure. 10:31.700 --> 10:32.050 Right now, 10:32.050 --> 10:32.860 at this point, 10:32.860 --> 10:35.630 we have started to take this off the exhaust 10:35.630 --> 10:36.070 osi's. 10:36.070 --> 10:36.870 You see now, 10:38.090 --> 10:40.710 what I do at this point is to get the skin, 10:40.710 --> 10:43.350 try to get the skin out as quickly as 10:43.350 --> 10:43.870 possible. 10:43.870 --> 10:46.860 I will dissect this down and roll the table towards me 10:46.860 --> 10:49.770 a little more as far as I can conveniently do so 10:49.890 --> 10:52.460 and then take out the outer half of the skin, 10:53.800 --> 10:54.390 hold it, 10:58.940 --> 11:01.760 get it down as far as I can get it this way and then 11:01.760 --> 11:03.050 get it out of the ear. 11:03.060 --> 11:03.520 Alright. 11:03.950 --> 11:06.780 And getting it out of the ear means putting an instrument. 11:06.780 --> 11:07.510 Why am I doing, 11:07.510 --> 11:10.420 putting an instrument here and sort of a vaulting 11:10.420 --> 11:11.230 it like this. 11:11.240 --> 11:11.550 I don't, 11:11.560 --> 11:14.330 I don't try to cut it gently and so forth 11:14.340 --> 11:16.150 because I found that when I do that 11:17.050 --> 11:17.890 too is, 11:18.650 --> 11:19.970 is frustrate myself. 11:19.970 --> 11:22.780 I just sort of put it down like that and pull out. 11:22.790 --> 11:23.160 You see, 11:23.160 --> 11:26.140 I've dissected the skin down to that point and I just put it 11:26.140 --> 11:27.730 down and sort of 11:28.930 --> 11:29.620 elevated, 11:29.630 --> 11:30.590 so to speak. 11:30.600 --> 11:31.110 Huh? 11:32.510 --> 11:35.410 Put it down here like this in our 11:35.410 --> 11:37.440 instrument in and then just sort of, 11:38.850 --> 11:41.650 if we can want to get as much as we can 11:41.650 --> 11:43.830 without spinning our wheels, 11:43.830 --> 11:44.750 so to speak. 11:49.380 --> 11:49.570 Now, 11:49.570 --> 11:52.550 this is not the way I used to do when I first started 11:52.550 --> 11:52.860 doing, 11:52.860 --> 11:54.360 these the first one I ever did, 11:54.360 --> 11:56.140 I'll never forget it back in about 11:56.140 --> 11:57.500 1959 11:58.930 --> 12:01.780 and I did it through the ear canal and I learned my lesson 12:01.780 --> 12:02.100 there. 12:02.100 --> 12:04.900 I had an ear drum to repair and all 12:04.900 --> 12:05.870 sorts of problems. 12:05.870 --> 12:07.630 It's just not adequate exposure, 12:08.430 --> 12:10.620 just not adequate exposure 12:12.190 --> 12:14.370 if I can get this out here. 12:14.380 --> 12:14.660 See, 12:14.660 --> 12:15.240 here again, 12:15.240 --> 12:15.570 I'm, 12:15.580 --> 12:17.380 I'm fiddling around right now. 12:17.380 --> 12:18.460 I'm wasting time. 12:18.470 --> 12:19.820 There's no point in trying to 12:20.900 --> 12:21.670 two. 12:21.750 --> 12:24.610 You can't get all the skin out the way you'd like 12:24.620 --> 12:25.660 to in these cases. 12:25.660 --> 12:28.570 So you just go ahead and sort of reach 12:28.570 --> 12:29.430 in and pull it, 12:29.840 --> 12:31.310 which is what I'm doing now. 12:31.310 --> 12:32.800 And should have done a minute ago. 12:32.800 --> 12:33.200 All right. 12:33.200 --> 12:33.380 Now, 12:33.380 --> 12:33.970 at this point, 12:33.970 --> 12:35.440 we ought to be able to take this out. 12:35.440 --> 12:35.580 Yeah, 12:35.590 --> 12:36.900 let me have a couple more steps. 12:38.240 --> 12:39.790 This is our canal skin. 12:39.790 --> 12:39.990 Now, 12:39.990 --> 12:41.430 we immediately go to the drill, 12:41.440 --> 12:42.070 rolling 12:44.300 --> 12:45.330 the water down a bit, 12:48.310 --> 12:49.330 a little bit more. 12:51.140 --> 12:52.100 Okay off a bit 12:54.040 --> 12:54.670 good. 12:55.460 --> 12:56.020 So, 12:56.020 --> 12:58.180 we just put this in and start drilling 12:59.040 --> 13:01.720 like this now as you drill in. 13:02.440 --> 13:02.840 Oh, 13:02.850 --> 13:04.070 let me have a rose and needle. 13:04.070 --> 13:07.060 Let me show you the pattern that you watch as you drill in. 13:08.080 --> 13:08.430 Well, 13:08.440 --> 13:11.090 here's where one of the big exhaust osi's was. 13:11.090 --> 13:12.860 Here's another one and here's another one. 13:12.860 --> 13:14.210 And if you look at this pattern, 13:14.210 --> 13:16.440 you see this is skin here, 13:16.450 --> 13:19.390 there's a pattern and it follows a typical pattern of A 13:19.390 --> 13:20.130 Y, 13:20.440 --> 13:22.240 one arm of the Y is here, 13:22.240 --> 13:24.780 one arm of the Y is there and the other one is 13:24.780 --> 13:27.470 there and it follows that pattern. 13:27.470 --> 13:30.440 And what you do is you keep drilling down with the center 13:30.440 --> 13:32.840 of your drilling right at this point here, 13:32.850 --> 13:35.400 always staying on the lower side 13:35.460 --> 13:37.370 because you don't want to remember. 13:37.370 --> 13:40.270 Don't forget your drum is nearer to you post eerily and 13:40.270 --> 13:43.040 superior early than it is anterior and inferior early. 13:43.110 --> 13:44.820 So you sort of center, 13:44.820 --> 13:47.120 you're drilling right at this point here. 13:47.370 --> 13:47.740 Now, 13:47.740 --> 13:50.480 as that area of soft tissue gets 13:50.480 --> 13:52.760 bigger opens up, 13:52.770 --> 13:55.430 that means you're getting past your exhaust Asus. 13:55.430 --> 13:58.290 And at that point when it starts to open up and there's 13:58.290 --> 13:59.600 more soft tissue, 13:59.790 --> 14:02.780 then you start working on individual 14:02.780 --> 14:05.710 exhaust and elevating the skin in 14:05.710 --> 14:06.250 front of you. 14:06.250 --> 14:06.560 Alright, 14:06.560 --> 14:07.460 let's have a drill. 14:16.370 --> 14:16.720 Now, 14:16.720 --> 14:19.040 I am not concerned the two areas, 14:19.050 --> 14:21.620 the areas that concern me in terms of my drilling, 14:21.620 --> 14:24.410 I don't want to get into the annoyed fossa 14:24.410 --> 14:27.390 and cherry really if I can help 14:27.390 --> 14:30.370 it and I don't want to get onto the drum or into 14:30.370 --> 14:30.500 the, 14:30.500 --> 14:31.690 onto the article. 14:31.700 --> 14:33.400 So I tend to stay, 14:33.530 --> 14:34.450 I keep my, 14:34.450 --> 14:37.220 I tend to stay directed a little bit inferior and 14:37.220 --> 14:37.970 interior, 14:38.230 --> 14:41.090 but keep watching to make sure that I'm not getting 14:41.090 --> 14:42.230 into soft tissue, 14:42.490 --> 14:44.700 I probably will get into soft tissue. 14:44.700 --> 14:47.280 But uh I don't want to get into it much. 14:47.280 --> 14:48.100 Let's put it this way. 14:48.100 --> 14:49.930 You want to recognize it when you do, 14:49.930 --> 14:51.110 let's put it that way. 14:52.430 --> 14:53.220 So at this point, 14:53.220 --> 14:53.840 we're working, 14:53.840 --> 14:55.210 you might extend some, 14:55.220 --> 14:58.190 some extent without being able to see past where we're 14:58.190 --> 14:58.600 working. 14:58.600 --> 15:01.170 But we're following down that soft tissue 15:01.760 --> 15:04.660 and knowing that and doing so that's where we're centering 15:04.660 --> 15:06.630 things that that's the way to go. 15:06.930 --> 15:09.560 I tell all these patients when I do these, 15:09.570 --> 15:10.720 that first place, 15:10.720 --> 15:12.500 I don't do them on the way they look, 15:12.510 --> 15:14.520 do them with rare exceptions, 15:14.520 --> 15:16.030 you do them because of symptoms. 15:16.720 --> 15:18.670 And I tell all of them that the, 15:18.680 --> 15:21.150 the major risk and complications 15:21.150 --> 15:23.730 involved is tearing the drum, 15:23.730 --> 15:26.700 which usually doesn't present much of a problem because you were 15:26.700 --> 15:29.700 repaired immediately and the other one is getting 15:29.700 --> 15:32.620 into our secular chain and getting into hearing loss 15:32.620 --> 15:33.950 as a result of a sensory. 15:33.950 --> 15:34.240 No, 15:34.240 --> 15:35.940 that's not happened to me yet, 15:36.460 --> 15:38.160 but I'm sure if I do enough of them, 15:38.160 --> 15:39.490 it will someday. 15:44.490 --> 15:46.960 This is a relatively typical one 15:48.170 --> 15:50.820 in that the exhaust go are 15:50.820 --> 15:52.200 continuing to go down. 15:52.200 --> 15:54.560 We're getting nearer and nearer to the drop. 16:01.280 --> 16:04.160 One of the things that make one of the many things that makes 16:04.160 --> 16:06.830 these tricky operations if you haven't done them 16:06.830 --> 16:07.540 before, 16:08.090 --> 16:10.990 is that constant question of how near to how 16:11.250 --> 16:12.440 did the drum am I? 16:12.450 --> 16:12.800 You know, 16:12.800 --> 16:14.420 you don't want to get into trouble. 16:15.710 --> 16:16.310 Well, 16:16.400 --> 16:17.720 there's a rule here. 16:18.390 --> 16:19.490 Your question about it. 16:19.490 --> 16:21.730 Always stay low and anterior. 16:21.730 --> 16:23.830 That's the secret low and anterior. 16:23.830 --> 16:25.750 That's where you have the most room. 16:27.620 --> 16:27.870 Now, 16:27.870 --> 16:29.410 let me show you something else you can do. 16:29.410 --> 16:30.880 Let me have a number one knife. 16:30.890 --> 16:31.120 Now, 16:31.120 --> 16:31.880 at this point, 16:31.880 --> 16:34.700 we're opening up a little bit and now we 16:34.700 --> 16:37.480 can try to open up this wire area 16:37.890 --> 16:39.720 and take a look to see how far, 16:39.730 --> 16:40.580 let me have a number. 16:40.590 --> 16:41.930 Let me have a number one knife. 16:41.940 --> 16:43.590 Here's our skin. 16:43.600 --> 16:44.320 We can start, 16:44.320 --> 16:47.290 we can take a peek and find out how near the drum we are at 16:47.290 --> 16:50.240 this point and then we'll push that skin back 16:50.240 --> 16:50.480 in. 16:50.480 --> 16:50.600 Now, 16:50.600 --> 16:51.890 there's your drum right there. 16:51.890 --> 16:52.680 Do you see that? 16:53.020 --> 16:53.910 There's the drum? 16:54.830 --> 16:57.760 Let's take a closer look at that and I want you to 16:57.760 --> 17:00.740 look not only where the drum is but the general 17:00.750 --> 17:01.940 angle of the drum. 17:01.940 --> 17:02.870 If you look in here, 17:02.870 --> 17:05.870 now we open that up and there's 17:05.870 --> 17:06.540 your drum. 17:06.550 --> 17:07.830 Okay. 17:08.220 --> 17:08.550 Now, 17:08.550 --> 17:10.490 notice that the drum goes, 17:10.500 --> 17:12.270 if you can see the orientation, 17:12.270 --> 17:13.660 let me get you back. 17:13.700 --> 17:16.680 Notice that the drum in that area is in this 17:16.680 --> 17:19.410 plane and that's the plane in which I've been 17:19.410 --> 17:20.050 drilling, 17:20.190 --> 17:22.790 constantly keeping the deepest area of 17:22.790 --> 17:25.500 penetration and clearly inferior early. 17:25.510 --> 17:27.130 So that as you go in, 17:27.140 --> 17:29.910 you go in parallel to the drum surface 17:29.920 --> 17:31.360 on. 17:34.880 --> 17:35.180 Alright, 17:35.180 --> 17:35.590 again, 17:35.590 --> 17:38.340 I'm gonna stay anterior and inferior. 17:43.980 --> 17:46.860 The reason being you don't want to expose 17:46.860 --> 17:49.670 yourself up there until you've got a 17:49.670 --> 17:52.280 better view of things because that's where you're gonna get into 17:52.280 --> 17:55.030 obstacles and gonna get near the drum much quicker. 18:07.620 --> 18:08.570 At this point. 18:08.570 --> 18:10.050 I'm beginning to 18:11.800 --> 18:13.770 let's have the next smaller size drill. 18:13.770 --> 18:13.920 Now, 18:13.920 --> 18:14.600 at this point, 18:14.600 --> 18:16.740 I'm beginning to scoop out the exhaust 18:17.310 --> 18:19.460 and leave an eggshell type of thing. 18:19.460 --> 18:22.390 I'm not drilling on the area where their 18:22.390 --> 18:23.040 skin is. 18:23.040 --> 18:25.940 I'm drilling back from that so that I'm trying to egg 18:25.940 --> 18:28.210 shell and then I can go in with a cure it and knock it off. 18:28.220 --> 18:28.670 You see, 18:29.640 --> 18:32.340 I realized that this is not a slide of this 18:32.340 --> 18:33.190 patient's ear, 18:33.190 --> 18:35.680 but I wanted to point out something when I, 18:35.680 --> 18:37.410 we go back into this sequence, 18:37.410 --> 18:40.190 you watch right down in this area here and I 18:40.190 --> 18:42.710 expose the facial nerve in the ear canal 18:43.360 --> 18:45.700 and I'll comment on it later on, 18:45.910 --> 18:48.650 but you'll notice that because I've done this and I 18:48.650 --> 18:51.330 realized that I started to change my 18:51.330 --> 18:52.230 procedure bit, 18:52.230 --> 18:54.880 working more anterior and inferior early and 18:54.880 --> 18:57.330 being a bit more cautious than I might. 18:57.570 --> 19:00.430 And I thought it might be a interest to you in connection with 19:00.440 --> 19:02.110 exposing the facial, 19:02.110 --> 19:05.100 in the ear canal to take a look at some of the drawings by Ward 19:05.100 --> 19:05.500 Litten. 19:05.760 --> 19:06.760 I apologize. 19:06.770 --> 19:08.500 All the lettering is backwards, 19:08.500 --> 19:11.180 but that's so that I can set this up as a right ear 19:11.190 --> 19:13.070 hears the tim panic membrane and 19:14.190 --> 19:16.780 this is the tim panic course of the facial 19:17.160 --> 19:18.500 and the mastoi portion. 19:19.180 --> 19:22.060 And this drawing is out of an article by Ward Litton 19:22.250 --> 19:24.680 that appeared in the September 69 19:24.680 --> 19:27.620 Laryngoscope as I was working down the ear 19:27.620 --> 19:28.090 canal, 19:28.090 --> 19:31.040 I actually got enough posterior to expose the 19:31.040 --> 19:33.410 facial nerve at about this point here. 19:33.730 --> 19:33.940 Now, 19:33.940 --> 19:36.370 if we look at this in another orientation 19:37.000 --> 19:37.520 here, 19:37.780 --> 19:39.410 we're looking from behind forward. 19:39.410 --> 19:41.380 Here's the tim panic membrane Angeles, 19:41.660 --> 19:42.960 here's the facial nerve, 19:43.130 --> 19:46.030 I exposed the facial nerve right at this point. 19:46.030 --> 19:48.980 Here just goes to show that you can 19:48.980 --> 19:50.900 encounter the facial anywhere in the air. 19:50.900 --> 19:53.290 The important thing is to realize that you're there. 20:12.650 --> 20:15.430 Here's a case where the word visualize is 20:15.430 --> 20:16.770 quite properly used. 20:16.770 --> 20:18.990 You've got to visualize the air drum 20:19.380 --> 20:21.130 because you can't really see it. 20:21.130 --> 20:21.610 Well, 20:22.540 --> 20:25.460 you've got to visualize where it is in terms of your 20:25.460 --> 20:26.050 working. 20:35.780 --> 20:38.320 I'll get a little bit more vision and so forth. 20:39.660 --> 20:39.890 No, 20:39.890 --> 20:40.750 if it doesn't want to, 20:41.620 --> 20:42.330 there we go. 20:42.340 --> 20:42.960 Okay. 20:53.400 --> 20:55.340 And we'll switch to a diamond bar. 20:56.520 --> 20:58.170 One thing I could have done here, 20:58.170 --> 20:59.590 but I elected not to. 20:59.590 --> 21:00.620 I was a little, 21:00.620 --> 21:03.450 I was a little bit surprised to find out I was this low down 21:03.450 --> 21:03.930 here. 21:04.620 --> 21:05.160 Therefore, 21:05.160 --> 21:06.980 I want to explore this more. 21:06.980 --> 21:09.130 I could have left these edges of bone 21:09.810 --> 21:11.660 as a protection of my skin flat, 21:11.660 --> 21:13.260 but I'm going to switch to a diamond. 21:13.260 --> 21:15.140 So I don't really have to do that. 21:15.140 --> 21:15.500 All right. 21:15.510 --> 21:16.270 Take this. 21:17.270 --> 21:19.340 Let me have the weapon again, 21:19.340 --> 21:19.700 please. 21:19.700 --> 21:21.940 Now we can open this up a bit more 21:23.670 --> 21:24.800 and take a little bit more. 21:24.800 --> 21:26.510 Look at it again. 21:26.520 --> 21:29.510 The secret of success in these is do it 21:29.520 --> 21:30.370 gently. 21:31.370 --> 21:32.270 Now this these, 21:32.280 --> 21:34.540 these really come right down on the drum. 21:34.540 --> 21:36.750 This bone really comes down on the drum. 21:36.750 --> 21:39.290 Now that I can see how deep I am 21:39.610 --> 21:41.340 and where I am now, 21:41.340 --> 21:44.040 I will go ahead push this skin back 21:44.040 --> 21:46.940 in and we'll go ahead 21:46.940 --> 21:48.070 with a diamond drill. 21:48.370 --> 21:51.270 I'm gonna work with a cutting board a little bit here 21:51.280 --> 21:53.870 superior because I've got quite a bulk of bone. 21:53.870 --> 21:54.140 Alright. 21:54.140 --> 21:54.760 Roll them. 22:16.000 --> 22:16.500 All right. 22:16.510 --> 22:16.840 Now, 22:16.840 --> 22:19.710 let's go ahead and take a look here and see if we can at this 22:19.710 --> 22:20.070 point. 22:20.070 --> 22:22.320 See AMBO is what I'd like to be able to 22:22.320 --> 22:23.320 identify. 22:24.330 --> 22:24.890 Alright, 22:25.190 --> 22:26.810 Dumbo is gonna be in here. 22:27.030 --> 22:28.440 We're posterior to it. 22:29.630 --> 22:30.070 Okay. 22:30.070 --> 22:30.920 We're right now. 22:31.400 --> 22:34.280 We are right at the annular ligament here after we 22:34.280 --> 22:37.280 get this bone off and I'm gonna leave that bone now as 22:37.280 --> 22:39.850 a protection and we'll go ahead and work up here. 22:39.850 --> 22:42.300 We're still way posterior 22:42.300 --> 22:42.890 apparently. 22:43.070 --> 22:43.970 All right 23:01.120 --> 23:01.910 off. 23:01.920 --> 23:04.120 Let's have the next smaller sized bird 23:18.410 --> 23:19.930 at this point. 23:20.080 --> 23:20.880 As you see, 23:20.880 --> 23:23.620 I've identified the drum and I know my direction 23:24.290 --> 23:25.080 at this point. 23:25.080 --> 23:27.940 I'm sort of keeping an eye on how thin the bone is 23:27.940 --> 23:28.370 getting. 23:28.370 --> 23:31.370 Plus seeing if I get to 23:31.370 --> 23:31.850 the bone, 23:31.850 --> 23:33.310 it looks like the annular, 23:33.320 --> 23:34.390 bony annular, 23:35.940 --> 23:38.150 but I'm drilling inside this shelf, 23:38.890 --> 23:41.530 keeping it thinning it down as I go 23:42.190 --> 23:44.650 and it is protecting me from the eardrum 23:50.690 --> 23:52.800 question that's often asked in these, 23:52.800 --> 23:53.060 well, 23:53.060 --> 23:55.690 with all this and taking all the skin out, 23:55.690 --> 23:57.480 how often do you get a stenosis, 23:57.490 --> 23:58.160 do you know, 23:59.110 --> 23:59.880 knock on wood? 23:59.880 --> 24:02.050 I've not had one with this. 24:02.050 --> 24:04.740 I think that that's unusual in my experience 24:06.990 --> 24:09.420 here is the way I've done them for years 24:10.550 --> 24:12.710 and I'm not aware of having one. 24:14.690 --> 24:17.660 I suspect somebody else has seen one or two of mine, 24:17.660 --> 24:18.890 maybe if I had any, 24:18.890 --> 24:20.110 but I haven't seen him. 24:23.120 --> 24:25.230 They just seem to do beautifully. 24:25.500 --> 24:28.430 They end up by being covered with skin 24:28.440 --> 24:29.460 for the most far. 24:34.940 --> 24:35.430 All right. 24:35.430 --> 24:35.740 Now, 24:35.740 --> 24:37.230 let me have the stay peas, 24:37.230 --> 24:40.110 cure it and we'll take off some more of the bone here 24:40.110 --> 24:40.950 and flip it off. 24:40.960 --> 24:42.630 It looks relatively thin 24:45.760 --> 24:46.510 like this. 24:46.520 --> 24:47.060 Huh. 24:49.260 --> 24:51.600 Put it in trying to get it off. 24:51.610 --> 24:53.360 Leaving the skin behind 24:54.320 --> 24:55.250 like this. 24:58.980 --> 24:59.610 Her, 25:05.040 --> 25:06.380 let me have a forceps. 25:06.390 --> 25:07.170 No, 25:07.180 --> 25:07.560 don't 25:14.540 --> 25:17.190 in all these maneuvers I'm doing now where I'm 25:17.190 --> 25:18.610 slipping an instrument in. 25:18.610 --> 25:21.540 You've got to be careful not to put pressure down on 25:21.540 --> 25:22.140 the drum. 25:22.140 --> 25:23.040 You slip it in, 25:23.040 --> 25:25.440 but be careful when you do that you don't. 25:25.440 --> 25:27.240 And when you go to curate the bone off, 25:27.250 --> 25:29.290 I'm prying it off like this. 25:29.290 --> 25:32.210 I'm not doing this with it because you 25:32.210 --> 25:34.800 could easily touch the 25:34.800 --> 25:36.610 obstacles and get into trouble. 25:37.680 --> 25:40.460 So I'm actually putting it in here and using it as a 25:40.460 --> 25:40.890 lever. 25:40.890 --> 25:42.100 Do you see like that? 25:42.110 --> 25:42.960 There we go. 25:45.130 --> 25:46.340 It's fun operation. 25:46.340 --> 25:47.100 It's kind of tricky, 25:47.100 --> 25:49.290 but it's kind of fun to do because it's different, 25:49.290 --> 25:49.580 you know, 25:49.580 --> 25:51.130 new and different type of thing. 25:58.120 --> 25:58.520 See, 25:58.520 --> 26:00.690 here's a case where you have to be very careful 26:00.910 --> 26:01.630 obstacles, 26:01.640 --> 26:02.610 short processes. 26:02.610 --> 26:04.190 That's bone of obstacle right there. 26:04.190 --> 26:06.160 And you gotta be very careful not to pry on it. 26:09.210 --> 26:12.160 So you can't do the curating the way you 26:12.160 --> 26:13.130 would normally do it. 26:13.130 --> 26:15.820 That's what I'm doing is not the way you normally cure it. 26:15.820 --> 26:17.580 You don't use a scraping motion, 26:18.670 --> 26:20.250 but that's what you're doing here. 26:20.510 --> 26:20.780 All right. 26:20.780 --> 26:21.050 Now, 26:21.050 --> 26:22.440 let me have the, 26:23.390 --> 26:24.680 let me have a number one knife. 26:24.690 --> 26:26.490 We're making good progress here. 26:26.490 --> 26:26.800 Now, 26:26.800 --> 26:28.510 you can begin to see the drum 26:30.010 --> 26:32.300 and there's the um bow right there. 26:32.300 --> 26:32.740 See, 26:32.990 --> 26:33.700 okay, 26:34.850 --> 26:35.800 at this point, 26:35.800 --> 26:38.620 we can begin to see how much more we've got to 26:38.620 --> 26:39.010 do. 26:39.020 --> 26:40.660 You want to get it all off, 26:40.670 --> 26:42.690 within limits weapons? 26:42.700 --> 26:45.390 You don't want to get it all off to the point that when you've 26:45.390 --> 26:47.300 finished it you've torn the drum. 26:48.810 --> 26:49.070 Well, 26:49.070 --> 26:51.140 let's see how much more we have to go here. 26:51.140 --> 26:51.350 Well, 26:51.350 --> 26:52.460 we've got a fair amount. 26:52.460 --> 26:55.180 You see that fair amount to go there. 26:55.880 --> 26:56.630 Okay. 26:56.640 --> 26:57.320 Roll them, 27:00.110 --> 27:01.520 turn the water down a bit. 27:32.030 --> 27:32.720 I have to stay, 27:32.720 --> 27:33.000 please. 27:36.930 --> 27:39.670 You'll notice I've still left some bone up in there. 27:39.680 --> 27:40.410 That's again, 27:40.410 --> 27:42.830 just so that I don't get into that area too 27:42.840 --> 27:45.530 closely until I really plan on it. 27:46.260 --> 27:46.700 In other words, 27:46.700 --> 27:49.550 I don't want to get into it by accident. 27:53.070 --> 27:55.850 So I like to go with this slow and easy, 27:56.710 --> 27:59.340 methodically and so forth and just take your 27:59.340 --> 28:00.910 time because you can really, 28:00.970 --> 28:03.970 you can really get into trouble with these and have a real 28:03.970 --> 28:05.150 mess on your hands. 28:05.160 --> 28:06.290 If you start, 28:06.300 --> 28:06.950 if you know, 28:06.950 --> 28:07.200 if, 28:07.210 --> 28:09.140 if you're not very careful with them, 28:10.030 --> 28:11.710 they are not easy to do 28:19.500 --> 28:22.490 another message to that is don't go doing them unless they need 28:22.490 --> 28:25.170 to be done because these are the interesting thing about these 28:25.170 --> 28:27.990 patients is as opposed to almost other, 28:28.000 --> 28:30.290 almost any other ear surgery you do. 28:30.290 --> 28:31.940 These patients don't have any trouble, 28:31.940 --> 28:33.130 they don't have any hearing loss, 28:33.130 --> 28:34.550 they don't have a draining ear. 28:34.560 --> 28:36.190 All they have is an ear. 28:36.190 --> 28:37.160 That looks odd. 28:37.660 --> 28:39.660 So you want to make sure they've got trouble, 28:40.240 --> 28:43.090 the warrants doing something and that trouble is 28:43.090 --> 28:45.840 usually recurrent episodes of Otitis external. 28:47.050 --> 28:50.040 I do keep an eye on some of these and if I've watched 28:50.040 --> 28:53.000 them and it's obvious they're getting worse and worse and 28:53.000 --> 28:53.320 worse, 28:53.330 --> 28:55.350 even though they haven't started to have symptoms, 28:55.350 --> 28:58.070 but it's obvious weapon that they are going to have to have it 28:58.080 --> 28:58.420 done, 28:58.730 --> 29:01.690 then it's a little bit easier to do it before it blocks it this 29:01.690 --> 29:02.180 much. 29:02.700 --> 29:03.720 But nonetheless, 29:03.730 --> 29:05.860 you don't want to get too eager with these. 29:05.860 --> 29:06.600 They are, 29:07.750 --> 29:09.600 they are cases which are 29:10.630 --> 29:12.670 fraught with all sorts of difficulties. 29:12.670 --> 29:14.960 I've got a little hematomas on the eardrum. 29:16.630 --> 29:18.710 Things are looking pretty good here. 29:20.310 --> 29:21.130 Inferior. 29:21.130 --> 29:21.340 Well, 29:21.340 --> 29:22.420 we've still got a ledge, 29:22.420 --> 29:22.690 huh? 29:23.040 --> 29:23.390 All right. 29:23.390 --> 29:24.920 Roll the table away some more. 29:24.920 --> 29:25.330 Would you 29:41.800 --> 29:43.030 let me have the staples, 29:43.030 --> 29:43.780 cure it again, 29:43.780 --> 29:44.300 please? 29:50.810 --> 29:53.710 I can use a fairly good sized Keret here because 29:53.710 --> 29:54.520 I'm away from the, 29:54.520 --> 29:54.720 um, 29:54.720 --> 29:56.320 bow in our secular chain. 29:58.520 --> 30:00.730 And at this point I'm fairly safe. 30:02.720 --> 30:03.990 It's fairly safe to do. 30:03.990 --> 30:04.310 So. 30:04.310 --> 30:04.850 I mean, 30:14.460 --> 30:16.600 you can do all this work with a drill, 30:16.600 --> 30:19.310 but I guess this just shows my antiquity. 30:19.310 --> 30:22.190 I learned to use a cure it many years ago 30:22.190 --> 30:24.000 in training and I like to do it. 30:26.360 --> 30:27.730 Let's have the weapon again, 30:27.730 --> 30:28.160 please. 30:34.020 --> 30:35.460 Uh, 30:35.470 --> 30:37.660 we're at the annular ligament right now. 30:37.750 --> 30:38.510 No, 30:38.520 --> 30:39.060 Dr. 30:39.060 --> 30:41.760 Christian will be closing within 15 30:41.760 --> 30:42.140 minutes. 30:46.900 --> 30:47.290 All right, 30:47.290 --> 30:49.310 we are at the annular ligament there. 30:49.310 --> 30:52.270 We still got a little bone that might be taken off at 30:52.270 --> 30:52.820 that point. 30:52.820 --> 30:53.940 But let's see now. 30:53.950 --> 30:54.430 Heck no, 30:54.430 --> 30:54.740 you see, 30:54.740 --> 30:56.550 you can see annular ligament already. 30:56.560 --> 30:57.030 You see, 30:58.180 --> 31:00.430 you can see the annual list right there. 31:01.820 --> 31:03.060 Let me show you something here. 31:03.060 --> 31:04.810 Something I was just analyzing. 31:04.810 --> 31:07.570 I think I've got facial nerve exposed in the ear canal. 31:07.570 --> 31:09.360 Let me take a look and see if I do. 31:09.360 --> 31:10.250 It could be. 31:11.310 --> 31:14.210 I saw it when I came on it right here. 31:14.210 --> 31:14.970 Do you see this? 31:14.980 --> 31:17.950 That's facial might as well pointed out 31:17.950 --> 31:19.770 to you because you don't often see this. 31:19.770 --> 31:20.830 Let me have a, 31:21.250 --> 31:22.260 let me point out what I did. 31:22.260 --> 31:24.420 You remember I said that as I was coming in, 31:24.420 --> 31:26.670 I was coming in a little far back here. 31:26.670 --> 31:27.770 Where do you see that white? 31:27.850 --> 31:30.730 That's facial nerve shows you can get to the 31:30.740 --> 31:32.400 facial nerve in the ear canal. 31:32.410 --> 31:35.250 You don't see that very often because you don't normally approach 31:35.250 --> 31:35.500 away. 31:35.500 --> 31:38.460 But that's facial nerve and it shows that the 31:38.470 --> 31:41.230 facial which is up would normally be lying medial to 31:41.230 --> 31:44.170 the medial ligament up here is now riding lateral to it on the 31:44.170 --> 31:45.790 course to the style mastoi. 31:45.790 --> 31:46.210 Huh? 31:46.220 --> 31:46.780 Okay. 31:47.360 --> 31:49.220 We're down to annular ligament there. 31:49.220 --> 31:50.910 We've got a bit up here. 31:51.260 --> 31:52.010 Not a lot. 31:53.690 --> 31:56.500 Let me have a cutting bird next to 31:56.500 --> 31:58.930 the uh medium. 32:00.610 --> 32:00.760 Now, 32:00.760 --> 32:03.210 what I'm gonna do is I'm gonna use a cutting burr 32:03.210 --> 32:05.910 lateral to the next smaller 32:05.910 --> 32:06.470 size. 32:06.940 --> 32:08.660 You see the apex, 32:08.670 --> 32:10.540 the apex of this bone right here. 32:10.540 --> 32:11.580 Right where I'm touching, 32:11.580 --> 32:12.260 I'm gonna use, 32:12.260 --> 32:13.670 I'm gonna work lateral to that. 32:13.670 --> 32:16.430 And that way I know I'm lateral to hospitals and I'm going to thin it 32:16.430 --> 32:18.580 down with a cutting burr. 32:18.670 --> 32:20.190 Both on. 32:22.020 --> 32:24.770 We're just going to thin this down with a cutting bird 32:24.890 --> 32:26.510 and create sort of a shell. 32:37.590 --> 32:40.130 The shelf turned the water down just a bit. 32:40.130 --> 32:43.030 The shell protects us from the articles from the 32:43.040 --> 32:43.720 skin, 32:43.730 --> 32:44.720 from the eardrum. 32:44.720 --> 32:45.240 You see, 32:46.010 --> 32:47.960 the shelf is getting very thin. 32:47.970 --> 32:48.510 In fact, 32:48.510 --> 32:50.710 it's almost cut through at this point. 32:55.900 --> 32:56.070 Now, 32:56.070 --> 32:57.730 let's have a staple cure right now. 32:57.730 --> 33:00.710 We'll take that off like this, 33:02.080 --> 33:02.410 huh? 33:03.530 --> 33:04.480 Okay. 33:07.680 --> 33:08.040 Art. 33:10.660 --> 33:12.810 So at that point that leaves us with a little bit, 33:12.810 --> 33:15.800 we can take off here with the cure and you 33:15.800 --> 33:18.440 can oftentimes finish it in this portion up here. 33:18.440 --> 33:18.570 Now, 33:18.570 --> 33:21.190 this is the difficult angle to get done is this 33:21.190 --> 33:22.730 anterior superior angle. 33:23.510 --> 33:25.740 But whereas in our tim panic membrane drafting, 33:25.740 --> 33:26.610 it's important. 33:27.000 --> 33:29.530 It's not here because it's all going to be covered by skin. 33:29.530 --> 33:30.980 You see now, 33:30.980 --> 33:31.540 at this point, 33:31.540 --> 33:34.240 we can also come back here and take off some of 33:34.240 --> 33:36.020 this right next to the 33:37.210 --> 33:37.720 All right. 33:37.720 --> 33:37.990 Now, 33:37.990 --> 33:40.860 let me have now a weapon as I think we're near to the 33:40.860 --> 33:42.480 point where we're gonna be through here. 33:42.480 --> 33:43.710 Let's just take a look, 33:44.200 --> 33:45.810 fold our skin back up, 33:45.810 --> 33:48.580 see where we stand how much we got left 33:50.240 --> 33:52.510 unfold the skin like this. 33:57.440 --> 33:57.890 Now there's, 33:57.900 --> 34:00.870 there's swelling over the drum and I can't see the 34:00.870 --> 34:01.860 short process, 34:01.860 --> 34:03.990 but I can feel short processes right there. 34:03.990 --> 34:05.870 We are above the short process. 34:08.770 --> 34:09.390 All right. 34:09.400 --> 34:09.580 Now, 34:09.580 --> 34:10.520 what have we got here? 34:10.520 --> 34:10.730 Well, 34:10.730 --> 34:12.450 we got a little overhang up here, 34:12.450 --> 34:15.340 but this is almost cosmetic from this point on. 34:15.340 --> 34:18.220 I'm gonna just take a little of this off to make it look 34:18.220 --> 34:18.700 pretty. 34:20.040 --> 34:22.730 I'm gonna cut this flat down to about the 34:22.730 --> 34:23.740 level of the annual. 34:23.740 --> 34:25.940 It's just so that it will lie flat like that. 34:25.940 --> 34:27.880 Otherwise it would hang up a bit. 34:27.890 --> 34:28.410 You see? 34:29.340 --> 34:29.690 All right, 34:29.690 --> 34:30.670 let me have, 34:30.680 --> 34:31.930 let me have the weapon. 34:39.620 --> 34:40.290 That attorney. 34:44.120 --> 34:45.260 Okay. 34:47.720 --> 34:47.890 Well, 34:47.890 --> 34:48.420 Jerry, 34:48.420 --> 34:51.350 I think we are ready to have some packing right 34:51.350 --> 34:51.830 now. 34:53.620 --> 34:54.540 Drum looks good. 34:54.540 --> 34:57.300 Now you can tell that there's no hole in the drum because the drum is 34:57.300 --> 34:59.220 bulging because of his anesthesia. 34:59.500 --> 35:01.050 She just balls right out. 35:01.060 --> 35:01.510 You see it. 35:03.740 --> 35:04.790 And uh, 35:04.800 --> 35:05.970 so that's very helpful. 35:05.970 --> 35:08.770 Normally the anesthesiology is not very helpful in these 35:08.770 --> 35:09.220 cases, 35:09.220 --> 35:10.280 but he sure is here. 35:10.280 --> 35:13.150 Let's have more and bigger. 35:16.580 --> 35:19.490 Now let me have the other canal skin. 35:24.530 --> 35:25.880 It doesn't look very good, 35:25.880 --> 35:26.600 but it's alright. 35:26.600 --> 35:27.490 Let's have a ring. 35:30.670 --> 35:30.980 Well, 35:30.980 --> 35:33.110 I usually advance it in a bit. 35:33.120 --> 35:34.340 Normally I don't, 35:34.350 --> 35:37.160 normally you're missing an area and I 35:37.170 --> 35:39.250 leave a little royal external. 35:40.090 --> 35:40.510 Yeah, 35:41.390 --> 35:44.390 between it and the other skin and so forth. 35:52.150 --> 35:54.710 Try to make sure the skin edges are rolled 35:54.710 --> 35:55.170 out. 35:59.190 --> 35:59.460 All right. 35:59.460 --> 36:00.570 Let's have packing. 36:05.000 --> 36:05.540 Okay. 36:05.550 --> 36:05.920 Roll. 36:05.920 --> 36:06.710 That's fine. 36:07.330 --> 36:08.060 That's good. 36:20.570 --> 36:21.350 I didn't, 36:21.520 --> 36:24.350 I didn't show putting the vascular strip back in place, 36:24.350 --> 36:25.570 but essentially what I did, 36:25.570 --> 36:28.430 I put all the skin back in place and then put the vascular 36:28.430 --> 36:29.580 strip back in place, 36:29.860 --> 36:31.640 packed the ear with gel foam, 36:31.940 --> 36:34.930 uh with gel foam soaked with some quarter 36:34.940 --> 36:36.500 spore in solution. 36:36.850 --> 36:39.850 And the postoperative care is to leave all this 36:39.850 --> 36:41.990 alone for about 10 days. 36:41.990 --> 36:44.160 Then you can aspirated in the office. 36:44.420 --> 36:46.980 And if the year has any drainage problem, 36:46.980 --> 36:49.200 which it sometimes does with granule ations, 36:49.300 --> 36:51.150 I put them on dilute vinegar, 36:51.150 --> 36:51.670 swishes, 36:51.670 --> 36:52.960 half strength white vinegar. 36:53.990 --> 36:56.940 Let me show you a little bit about this matter of the osteo um of the 36:56.940 --> 36:57.410 ear canal. 36:57.420 --> 36:58.700 This is what it looks like. 36:59.370 --> 37:02.300 Notice that it's normally attached at 37:02.310 --> 37:04.850 the junction of the outer and middle third of the year 37:04.850 --> 37:07.610 canal and it presents itself just in this way 37:08.490 --> 37:11.450 and uh the treatment of its 37:11.450 --> 37:12.530 relatively simple. 37:13.060 --> 37:13.270 Now, 37:13.270 --> 37:16.030 there have been a number of different ways that have been recommended at 37:16.040 --> 37:18.650 times to approach problems of the ear canal. 37:18.950 --> 37:21.940 I don't recommend any of these for the most 37:21.940 --> 37:22.440 part. 37:22.710 --> 37:24.510 But here is one that fact, 37:24.520 --> 37:26.460 in fact depicts what you do. 37:27.100 --> 37:29.900 You don't do it in the office or with a patient standing up, 37:29.900 --> 37:32.180 but you take a little mallet and 37:32.180 --> 37:34.900 gouge and you tap it and it falls 37:34.900 --> 37:37.860 off the way you can do that 37:37.860 --> 37:40.260 is this here shows you a view, 37:40.490 --> 37:41.810 you're looking into the air canal, 37:41.810 --> 37:42.850 you have this podunk, 37:42.850 --> 37:42.970 yah, 37:42.970 --> 37:45.620 lated unilateral osteo MMA 37:45.630 --> 37:47.780 attached to the Timpano squamous suture. 37:48.860 --> 37:51.600 What you normally do working through the air 37:51.600 --> 37:51.990 canal, 37:51.990 --> 37:53.620 usually under local anesthesia. 37:53.620 --> 37:56.610 You can pass a hook down deep to this, 37:57.720 --> 37:59.170 take a little gouge, 37:59.180 --> 38:02.150 have your nurse tap it and the thing falls off 38:02.190 --> 38:04.430 and you can deliver it out the ear easily. 38:04.720 --> 38:07.700 You may want to take a little burr and burnish the base of it. 38:08.440 --> 38:08.950 Now, 38:08.960 --> 38:11.870 this is not what I'm going to show 38:11.870 --> 38:14.090 you on the tape 38:14.900 --> 38:15.990 because unfortunately, 38:15.990 --> 38:17.340 I didn't have a tape of this. 38:17.340 --> 38:19.840 But I have a very unusual case. 38:20.210 --> 38:22.860 This is of a doctor and he had a 38:22.860 --> 38:25.350 solitary osteo more of his ear canal, 38:25.350 --> 38:27.800 but it was attached right next to the short 38:27.810 --> 38:29.210 process of the malia's. 38:30.130 --> 38:31.040 And on him, 38:31.040 --> 38:33.750 I went in behind the ear doing this post to 38:33.750 --> 38:35.240 regularly under local. 38:35.590 --> 38:38.540 But I used the same technique finally to get it out. 38:38.690 --> 38:40.400 I passed something deep to it. 38:40.720 --> 38:43.530 I then put a gouge here at this point 38:43.530 --> 38:44.070 anyway, 38:44.150 --> 38:44.750 tapped it. 38:44.840 --> 38:45.950 And as you'll see, 38:46.100 --> 38:48.590 the osteo MMA fell away very 38:48.590 --> 38:49.130 nicely. 38:49.560 --> 38:52.120 Let's go to the T V tape. 38:52.710 --> 38:53.140 This, 38:53.150 --> 38:55.790 this patient has a solitary 38:55.790 --> 38:58.540 osteo Mahy in his left ear canal. 38:58.930 --> 39:01.170 And he's been under the observation of an ear, 39:01.170 --> 39:04.080 nose and throat man for oh 10 years or 39:04.080 --> 39:06.710 so and his ear gets plugged up occasionally and he's been 39:06.710 --> 39:09.640 watching the things slowly grow and referred him to me. 39:09.650 --> 39:12.270 He's got mild diffuse exhaust. 39:12.270 --> 39:13.870 Oh sis in both ears canal, 39:13.870 --> 39:14.760 both ear canals. 39:14.760 --> 39:15.580 This is no problem. 39:15.580 --> 39:17.360 This is a solitary osteopath. 39:18.110 --> 39:20.900 The only thing different about it is that solitary osteo Mazar 39:20.900 --> 39:23.760 normally unilateral as this is the 39:23.760 --> 39:26.320 only thing different about it is that they're normally in 39:26.320 --> 39:26.900 the, 39:26.910 --> 39:29.890 at the junction of the outer and middle third and they're usually 39:29.890 --> 39:32.070 attached to the temple suture line. 39:32.310 --> 39:35.020 This one is quite a bit further immediately than this. 39:35.430 --> 39:38.280 And whereas I might normally go through the ear canal 39:38.280 --> 39:38.660 here, 39:38.660 --> 39:40.510 I have gone post irregularly. 39:40.910 --> 39:41.070 Now, 39:41.070 --> 39:42.910 prior to the time we started the tape, 39:42.910 --> 39:44.640 I made a post auricular incision, 39:44.640 --> 39:45.750 turned the air forward, 39:45.750 --> 39:48.120 transected the ear canal and now we'll go to the 39:48.120 --> 39:49.740 microscope and take a look. 39:50.110 --> 39:50.280 Now, 39:50.280 --> 39:53.030 I realize I've transected the ear canal at about the 39:53.040 --> 39:55.990 junction of the outer and 39:55.990 --> 39:56.670 middle third. 39:56.670 --> 39:59.320 And this is way down in deep frozen 39:59.320 --> 39:59.700 needle, 40:01.230 --> 40:02.780 way down in deep. 40:02.780 --> 40:04.950 You can just barely see around it, 40:05.440 --> 40:07.100 but it's quite a bit different in that. 40:07.100 --> 40:09.940 They are normally attached out here at this level and you can 40:09.940 --> 40:11.720 easily do them trans canal. 40:12.380 --> 40:12.510 Now, 40:12.510 --> 40:13.620 this is not, 40:14.470 --> 40:15.860 And the question only. 40:15.870 --> 40:18.720 So I went post directly on it so that I could get a 40:18.720 --> 40:19.530 better view of it, 40:19.530 --> 40:21.080 but it's about three quarters, 40:21.090 --> 40:22.510 90% blocked. 40:23.050 --> 40:26.050 So what I'm doing at this point is cutting out the 40:26.050 --> 40:27.340 vascular strip area. 40:27.340 --> 40:27.510 Now, 40:27.510 --> 40:28.130 one could say, 40:28.130 --> 40:28.320 well, 40:28.320 --> 40:30.700 why didn't you leave it attached to the oracle? 40:31.070 --> 40:31.390 Well, 40:31.390 --> 40:33.690 I didn't because I didn't think it was gonna be 40:33.690 --> 40:36.120 necessary and it's a very little 40:36.120 --> 40:39.120 concern but I didn't and we'll excise 40:39.120 --> 40:41.620 the skin and then just put it back in when we get 40:41.630 --> 40:42.250 through. 40:48.630 --> 40:49.210 Now, 40:49.210 --> 40:50.390 let me have the, 40:50.400 --> 40:51.330 let me have a weapon, 40:51.330 --> 40:51.820 please. 40:58.150 --> 40:58.690 But Sammy, 40:58.690 --> 40:59.460 you can see this. 40:59.460 --> 41:01.990 It's not a very common place to have one of these. 41:03.530 --> 41:05.150 Usually if you see them, 41:05.150 --> 41:06.320 they're not very common. 41:06.320 --> 41:06.660 They're, 41:06.660 --> 41:08.210 they're right down there in the outer, 41:08.540 --> 41:10.380 there's much more lateral than this 41:11.770 --> 41:12.570 white players. 41:14.390 --> 41:14.660 Now, 41:14.660 --> 41:16.560 what I'm gonna do let me have a two knife. 41:16.560 --> 41:19.420 We're gonna try to cut across the base of this so that 41:19.420 --> 41:21.930 we can take this out and not a vault it 41:35.560 --> 41:38.210 and you can put this aside just as you would canal 41:38.210 --> 41:38.850 skin, 41:39.160 --> 41:39.740 Jerry, 41:43.380 --> 41:45.850 I get the impression that if I can get it 41:45.850 --> 41:46.580 loose, 41:46.990 --> 41:48.050 I can get it out. 41:48.050 --> 41:48.240 Now, 41:48.240 --> 41:50.210 I've passed medial to it here, 41:55.410 --> 41:57.950 but I'm not sure I can't feel myself getting 41:57.950 --> 41:58.620 around it. 42:00.400 --> 42:02.170 So we're gonna drill, 42:06.730 --> 42:08.470 I'm under it here, 42:10.370 --> 42:12.120 but I'm not under a tail. 42:13.060 --> 42:15.960 And as I said to you all this is exactly the reason that 42:15.960 --> 42:18.750 I wasn't gonna try to approach this from 42:18.760 --> 42:21.430 through the ear canal because I just did not want to get 42:21.440 --> 42:24.400 caught short on something. 42:24.400 --> 42:25.310 What I'm gonna do, 42:25.310 --> 42:27.140 I'm gonna take out the skin. 42:28.260 --> 42:29.800 Let's have a # two knife. 42:30.890 --> 42:33.600 I'm gonna take out the skin post eerily down to the 42:33.600 --> 42:36.600 level of the lesion and 42:36.600 --> 42:39.440 then I'm gonna drill down some of the bone post clearly to 42:39.440 --> 42:42.020 see if I can get some room there so I can see 42:42.020 --> 42:43.850 around it because right now 42:45.660 --> 42:47.210 I can't see around it. 42:48.940 --> 42:50.490 Let me have a cup forceps. 43:00.000 --> 43:00.490 Alright. 43:00.490 --> 43:02.840 You can put this in with the canal skin, 43:03.940 --> 43:04.650 roll them, 43:11.430 --> 43:12.760 turn the water down a bit, 43:12.770 --> 43:13.180 please. 43:17.910 --> 43:18.740 A little bit more. 43:18.740 --> 43:18.930 That, 43:18.940 --> 43:20.140 that's good right here. 43:30.590 --> 43:31.840 All right off. 43:31.850 --> 43:33.840 Let's go to the next smaller size bird. 43:49.550 --> 43:51.640 Let's have the next smaller size bird. 43:53.580 --> 43:56.550 And hopefully I will keep it from coming loose because 43:56.550 --> 43:57.800 I don't little more water. 43:58.910 --> 44:01.350 I can keep it from coming loose water. 44:03.210 --> 44:04.110 There we go. 44:04.250 --> 44:05.290 Turn it down a bit. 44:08.440 --> 44:10.160 Keep it from turning down a bit. 44:10.170 --> 44:10.880 There we go. 44:10.890 --> 44:13.550 Keep it from coming loose because if it does, 44:13.550 --> 44:16.070 why it will tend to impact immediately. 44:17.840 --> 44:20.440 But I did and they didn't remark on it to you 44:20.440 --> 44:20.860 doctor. 44:20.860 --> 44:23.730 I went down below it and hooked under it to see if I 44:23.730 --> 44:25.880 could move it and it seems pretty solid. 44:25.880 --> 44:26.520 Next, 44:27.260 --> 44:29.390 the next smaller size cutting burr. 44:29.860 --> 44:30.310 Alright. 44:30.310 --> 44:30.950 Roll them. 44:34.460 --> 44:34.610 Now, 44:34.610 --> 44:36.620 at this point with this delicate bird, 44:36.620 --> 44:39.530 I'm actually drilling right at the junction of the two 44:47.380 --> 44:50.040 because the reason is because I've got into a master 44:50.150 --> 44:52.970 cell there And I just assume 44:52.970 --> 44:54.600 not getting more to one. 45:00.000 --> 45:00.600 Alright. 45:00.600 --> 45:00.910 Off. 45:01.300 --> 45:01.980 Let's see. 45:01.980 --> 45:04.330 We'll put this down here like this. 45:06.150 --> 45:06.500 See, 45:06.500 --> 45:06.700 well, 45:06.700 --> 45:08.770 we can get that out from posterior. 45:08.770 --> 45:09.070 Really. 45:09.070 --> 45:11.110 We can pass around the lesion 45:12.140 --> 45:14.080 and it comes out posterior Lee. 45:15.440 --> 45:15.730 Oh, 45:15.730 --> 45:17.510 I think we're ready to go here now. 45:17.510 --> 45:19.810 I think we're ready to go roll the table away a bit. 45:19.820 --> 45:20.180 Please. 45:20.180 --> 45:22.200 Let's get out the small gouge. 45:23.670 --> 45:24.280 Hold it. 45:24.630 --> 45:24.840 Now, 45:24.840 --> 45:27.740 what I'm gonna do is to pass my hockey stick 45:29.570 --> 45:30.560 Deep to the lesion. 45:30.560 --> 45:33.470 Let me have a number three Baron deep to the 45:33.470 --> 45:34.040 lesion. 45:34.700 --> 45:37.620 Get behind it and then just try to tap it loose and 45:37.620 --> 45:38.420 roll it out. 45:40.120 --> 45:42.410 As long as I would feel that it's not going to 45:42.410 --> 45:43.210 impact. 45:43.210 --> 45:43.790 You see, 45:50.510 --> 45:53.470 we pass around the lesion and get under it. 45:53.480 --> 45:53.830 All right, 45:53.830 --> 45:54.500 it's under it. 45:54.510 --> 45:55.080 Now, 45:56.280 --> 45:59.280 now let me have the gouge in 45:59.280 --> 46:00.340 my left hand 46:02.050 --> 46:02.930 just a minute. 46:04.130 --> 46:04.760 Okay. 46:06.300 --> 46:06.770 Again. 46:07.440 --> 46:07.990 Again, 46:08.670 --> 46:09.360 hold it 46:11.360 --> 46:13.750 again again, 46:14.440 --> 46:14.900 hold it. 46:14.900 --> 46:15.930 That moved it, 46:16.720 --> 46:18.460 that moved it up. 46:18.460 --> 46:19.240 It's movable. 46:20.870 --> 46:23.800 I may have to drill on that pete uncle. 46:23.800 --> 46:24.300 Let's see. 46:24.300 --> 46:26.460 I'm gonna see if I now here it comes, 46:26.460 --> 46:26.920 it's loose. 46:26.920 --> 46:27.550 See it coming. 46:27.650 --> 46:28.240 Okay. 46:29.540 --> 46:30.000 Okay. 46:30.000 --> 46:30.800 It's loose. 46:33.300 --> 46:33.990 Here it comes. 46:34.000 --> 46:34.760 Okay. 46:37.160 --> 46:38.880 Let me have the hockey stick again. 46:40.020 --> 46:40.860 Okay. 46:42.680 --> 46:45.070 And now we can see the eardrum for the first time 46:45.450 --> 46:46.680 down this little hole. 46:53.440 --> 46:54.950 That's a good sized one. 46:58.420 --> 46:59.290 Okay. 46:59.300 --> 47:00.400 Let me have a forceps. 47:03.880 --> 47:04.270 Well, 47:04.270 --> 47:06.440 no wonder it had quite a broad attachment. 47:06.440 --> 47:07.050 Look at that. 47:07.060 --> 47:07.800 You see that, 47:08.580 --> 47:11.550 that's a tremendously broad attachment all along 47:11.550 --> 47:12.430 the suture line. 47:15.120 --> 47:15.360 Well, 47:15.360 --> 47:18.180 I'm happy to say that this doctor 47:18.190 --> 47:20.950 who had this very unusual osteo my, 47:20.950 --> 47:22.400 I've never seen anything like it. 47:22.400 --> 47:23.850 He got along very nicely. 47:24.100 --> 47:26.890 One thing I didn't show you on the tape because it was of no great 47:26.890 --> 47:29.810 importance was that he got a little tear in 47:29.810 --> 47:32.360 the parts flash because of the skin of the osteo. 47:32.360 --> 47:34.390 MMA was actually attached very tightly. 47:34.390 --> 47:36.870 I repaired this with a small under surface graft. 47:37.120 --> 47:38.490 Everything went along very nicely. 47:38.490 --> 47:40.170 I packed his ear with gel foam, 47:40.600 --> 47:43.260 took the gel phone out after about two weeks 47:43.260 --> 47:45.250 and the ear healed very nicely. 47:45.540 --> 47:48.130 So we've talked about two surgical problems. 47:48.220 --> 47:49.930 One of them very uncommon, 47:49.940 --> 47:52.920 the isolated yoma attached to the 47:53.030 --> 47:53.320 temple, 47:54.840 --> 47:57.320 the junction of the outer and middle third of the ear canal, 47:57.320 --> 48:00.210 not specifically like the one you just saw, 48:00.510 --> 48:02.350 this is invariably a surgical problem. 48:02.350 --> 48:04.830 The other one is very common problem. 48:04.840 --> 48:06.330 Often in swimmers, 48:07.090 --> 48:09.880 many of my patients are professional lifeguards. 48:10.310 --> 48:12.840 Uh the problem of diffuse 48:12.840 --> 48:13.410 exhaust. 48:13.410 --> 48:16.220 Oh sis which is bilaterally symmetrical usually 48:16.220 --> 48:18.860 does not require surgery unless the 48:18.860 --> 48:21.180 patient is having considerable symptom. 48:21.180 --> 48:24.050 Atala ji from it and it 48:24.060 --> 48:25.900 can be a difficult operation. 48:25.910 --> 48:27.040 Thanks for watching.