Fig. 15.1
Grommet
Indications
Bilateral otitis media with effusion (OME) of longer than 3 months duration.
Recurrent acute otitis media (AOM).
Complications of AOM e.g. mastoiditis or facial nerve palsy.
Meniere’s disease: to facilitate repeated gentamicin injections.
Prophylaxis: to reduce progression of a tympanic membrane retraction pocket and subsequent trapping of squamous cells (cholesteatoma).
Contraindications
Vascular middle ear tumour (e.g. glomus tumour).
Investigations
Otoscopy.
Tympanometry (to confirm a diagnosis of OME).
Audiometry.
Flexible nasal endoscopy to visualise the nasopharynx.
Step-by-Step Summary: Grommet Insertion
- 1.
The external auditory canal is visualised using an appropriately sized speculum.
- 2.
Wax and debris are cleared from the canal to visualise the tympanic membrane.
- 3.
The tympanic membrane is assessed to exclude secondary pathology, including attic defects or cholesteatoma.
- 4.
The tympanic membrane is incised antero-inferiorly to avoid damage to the ossicular chain.
- 5.
Excess fluid is aspirated to clear the middle ear.
- 6.
Crocodile forceps are used to grip the grommet with the flange protrusion forwards.
- 7.
The flange protrusion is placed through the tympanic membrane incision.
- 8.
The grommet is gently pushed until it is stable and secure.
- 9.
A single dose of topical antibiotic is given post-procedure.
Complications
Infection.
Bleeding.
Residual tympanic membrane perforation following extrusion of the grommet.
Tympanosclerosis (scarring of the tympanic membrane).
Premature extrusion of the grommet.
Follow Up
Check that the patient has not experienced excessive ear pain, otorrhoea, bleeding or fever like symptoms. These symptoms may indicate infection.
Outpatient audiology follow up to re-test hearing.
Ensure patency of the grommet at each follow-up appointment.
Tympanoplasty
A tympanoplasty is the reconstruction of the tympanic membrane. A graft, usually from the temporalis fascia, is taken and placed either medially (underlay) or laterally (overlay) to the tympanic membrane (Fig. 15.2). The aim of this procedure is to close off the middle ear in order to reduce infection rates. Closure may also benefit hearing in many cases. Tympanoplasty is a day case procedure.
Fig. 15.2
Tympanoplasty
Indications
Non-healing tympanic membrane perforation with one of the following:
Hearing loss.
Recurrent infections.
Need for intact tympanic membrane (e.g. swimmers).
Contraindications
Active infection of the ear (relative contraindication).
Investigations
Otoscopy.
Audiometry.
Step-by-Step Summary: Endaural Approach
There are three common surgical approaches to this procedure: endaural, postaural or transcanal. The endaural approach is particularly useful in that the attic can be easily visualized and is described below. The postaural approach may be used in anterior perforations.
- 1.
Local anaesthetic is injected along the incision line.
- 2.
Access to the ear canal is gained through an incision beginning at the 12 o’clock position and extending superiorly between the tragus and crus of the helix.
- 3.
A temporalis fascia graft is harvested.
- 4.
The edges of the tympanic membrane perforation are freshened to precipitate adhesion and healing of the graft.
- 5.
The canal incision is completed posteriorly to create a flap which is mobilised to the level of the annulus (surrounding border of the tympanic membrane).
- 6.
The annulus is elevated to enter the middle ear, freeing the tympanic membrane superiorly and inferiorly.
- 7.
The chorda tympani is identified and traced to the neck of the malleus.
- 8.
The ossicular chain is inspected for integrity and mobility to assess the need for ossiculoplasty.
- 9.
The graft is inserted into the middle ear, under the tympanic membrane, to close the perforation.
- 10.
Spongistan (a dissolvable material) is placed medial to the graft to aid adhesion to the perforation edge.
- 11.
The flaps are replaced and closure of the perforation is assessed, particularly anteriorly.
- 12.
Spongistan and a wick are placed in the ear canal.
Complications
Failure to close the perforation or recurrence of the perforation.
Tympanic membrane retraction.
Bleeding.
Infection.
Tinnitus.
Inner ear damage: can lead to vertigo or rarely sensorineural hearing loss.
Taste disturbance secondary to chorda tympani damage.
Follow Up
Follow-up appointment at 6 weeks and 6 months to make sure the perforation has healed and to check for formation of cholesteatoma (an abnormal collection of keritanised cells in the middle ear).
Core Operations: Nose
Septoplasty
The nasal septum separates the 2 nasal cavities. Patients can develop a deviated septum either as a developmental abnormality or as a result of trauma. Septoplasty involves the correction of any deviation to restore appropriate anatomy and relieve upper airway tract obstruction (Fig. 15.3).
Fig. 15.3
Septoplasty
Indications
Nasal obstruction due to deviated nasal septum.
Harvesting cartilage for use in rhinoplasty.
Surgical access (e.g transseptal-transsphenoidal approach for resection of pituitary tumour).
Contraindications
Large septal perforation.
Active infection in nose.
Coagulopathy.
Investigations
Anterior rhinoscopy using a speculum.
Nasal endoscopy.
Step-by-Step Summary: Septoplasty
- 1.
The nose is first decongested.
- 2.
Local anaesthetic with adrenaline is injected into the septal tissues.
- 3.
An anterior incision along the columella (external end of the nasal septum) is performed.
- 4.
The subperichondrial and subsequently the subperiosteal planes are carefully entered anteriorly.
- 5.
These flaps are elevated posteriorly to separate them from the septal cartilage and bone.
- 6.
The septal cartilage is separated from bone and any obstructive or deviated bone is removed.
- 7.
The cartilage is trimmed to fit and permit mobilisation to a more central position, avoiding reduction of the anterior height.
- 8.
The cartilage is sutured into the new columella pocket and the flaps are sutured back together to prevent septal haematoma.
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