Middle Ear Surgery PDF
Preview Middle Ear Surgery
H.Hildmann,H.Sudhoff · MiddleEarSurgery Henning Hildmann · Holger Sudhoff Middle Ear Surgery Withcontributionsby ManuelBernal-Sprekelsen JürgenLautermann StefanDazert JoachimMüller OrlandoGuntinas-Lichius AlexanderRauchfuss AndreGurr MartinScholz SergijeJovanovic MatthewYung With165Figuresin182Partsand9Tables Prof.Dr.med.Dr.hc.HenningHildmann Hals-Nasen-Ohren-KlinikderRuhr-UniversitätBochum St.Elisabeth-Hospital,Bleichstr.15,D-44787Bochum,Germany PDDr.med.HolgerSudhoff Hals-Nasen-Ohren-KlinikderRuhr-UniversitätBochum St.Elisabeth-Hospital,Bleichstr.15,D-44787Bochum,Germany ISBN3-540-22201-4 Springer-VerlagBerlinHeidelbergNewYork LibraryofCongressControlNumber:2006922214 Thisworkissubjecttocopyright.Allrightsarereserved,whetherthewholeorpartofthe materialisconcerned,specificallytherightsoftranslation,reprinting,reuseofillustrations, recitation,broadcasting,reproductiononmicrofilmorinanyotherway,andstorageindata banks.Duplicationofthispublicationorpartsthereofispermittedonlyundertheprovisions oftheGermanCopyrightLawofSeptember9,1965,initscurrentversion,andpermissionfor usemustalwaysbeobtainedfromSpringer-Verlag.Violationsareliabletoprosecutionunder theGermanCopyrightLaw. Springer-VerlagBerlinHeidelbergNewYork SpringerisapartofSpringerScience+BusinessMedia http://www.springeronline.com Springer-VerlagBerlinHeidelberg2006 PrintedinGermany Theuseofgeneraldescriptivenames,registerednames,trademarks,etc.inthispublication doesnotimply,evenintheabsenceofaspecificstatement,thatsuchnamesareexemptfrom therelevantprotectivelawsandregulationsandthereforefreeforgeneraluse. Productliability:Thepublisherscannotguaranteetheaccuracyofanyinformationaboutthe applicationofoperativetechniquesandmedicationscontainedinthisbook.Ineveryindivid- ualcasetheusermustchecksuchinformationbyconsultingtherelevantliterature. Editor:MarionPhilipp DeskEditor:IrmelaBohn Illustrations:HaraldKonopatzki ProductionEditor:JoachimW.Schmidt Coverdesign:eStudioCalamar,Spain Typesetting:FotoSatzPfeiferGmbH,D-82166Gräfelfing Printedonacid-freepaper–24/3150–543210 Foreword During the past 20 years, the ENT Department of the Ruhr University, Bochum,hasbeen,undertheleadershipofProfessorHenningHildmann,an importantcentrefortheteachingofotosurgery.Furthermore,duringthistime Bochum Clinic has become, mainly due to the efforts of Holger Sudhoff, a majorfocalpointforotologicalresearch.Acombinationoftwosucheminent earsurgeonsandtheircolleaguesisaguaranteeforaninformativeandinspir- ingbookonearsurgery. In Bochum Clinic, 17 Ear and Temporal Bone Surgery Courses have taken placeovertheyears,eachcoursewithanattendanceof60–80pupilsfromover theworld.Ihadtheprivilegetobeoneoftheteachersonthesecoursesandwas abletofollowtheoutstandingsurgeryofthecourseleaders,HenningHildmann and Jan Helms, both pupils of Dietrich Plester. It is therefore fitting that the bookismainlybasedontheideasandtechniquesofthispioneeringearsurgeon. Thebookisdividedinto34chapters,mostofwhicharewrittenbyHenning HildmannorHolgerSudhoff.Theremainingchaptersarewrittenbytheteach- ersofthecourseatBochum–allexpertsintheirspecialisttopics:Alexander Rauchfuss, Jürgen Lautermann, Martin Scholz, Sergije Jovanovic, Matthew Yungand,finally,StefanDazert,whoisthenewchairmanofBochumClinic andthenewDirectoroftheBochumEarandTemporalBoneSurgeryCourses. Themanychaptersonsurgicalmethodsarewellwrittenandeasytounder- stand, even for beginners in otosurgery. These chapters are illustrated with many beautiful, clear and realistic colour illustrations. Most of them do not needaspecialexplanationinthetext.Thesurgicalchaptersareenhancedby chaptersonpreoperativeevaluation,on„whennottodosurgery“andonpost- operativetreatment. EventhoughthetitleofthebookisMiddleEarSurgery,severaltopicsout- sidethemiddleearareincluded,makingthisbookevenmorecomplete. One cannot but admire Henning Hildmann and Holger Sudhoff who, besidestheirclinicalandadministrativework,surgeryandteaching,research andinternationalobligations,haveproducedthiswell-writtenandwell-illus- tratedworkduringthecourseofoneyear.Ibelievethatbothyoungandestab- lishedotosurgeonsallovertheworldwillenjoyandbenefitfromthisbook. MirkoTos,ProfessorEmeritusofOtolaryngology UniversityofCopenhagen,Denmark Preface Thisbookaimstogivetheyoungsurgeonastep-by-stepintroductiontomid- dleearsurgery,andwehopethattheexperiencedsurgeonwillalsofindideas andsuggestionswhichmayimproveroutinesurgeryandserveasabasisfor discussion. A systematic approach is provided to frequent otological opera- tions.Proceduresinsurgeryoftheearcanal,acuteandchronicmiddleeardis- eases, otosclerosis, cochlear implantation and vertigo are explained step-by- steptoacquaintthebeginnerwiththesurgicaltechniqueswhichhaveproven togivegoodresults. ThebookismainlybasedontheideasandtechniquesdevelopedbyDiet- richPlester,whohadamajorimpactonthedevelopmentofmiddleearsur- gery.Hissecretoftimeefficientandsuccessfulsurgerywasbasedonathor- oughpreoperativeassessmentofthecase,counsellingofthepatienttosetreal- isticexpectations,economicuseofafewinstruments,tendertreatmentofthe tissue and the use of standardized procedures without being too rigid. This approachtosurgeryisnotanunrealisticideal,butitisteachableandlearnable foranormallygiftedsurgeon.Theprincipleswere published intheGerman literature(byPlester,Hildmann,andSteinbach)15yearsago.Inthemeantime our experience has grown. Jan Helms must especially be mentioned for the numerous courses and otologic events we have conducted together. Indeed many of his ideas have contributed to this book. We thank our nationaland international friends and colleagues, as well as participants of workshops, roundtablesandconferencesforvaluableideas,hintsandcriticism.Wethank theteachersofourworkshopsandhostsincentresinmanypartsoftheworld. Thereforetheprinciplespresentedherearethefruitsofacquiredsurgicaland clinical knowledge over time. This is a surgical textbook; nevertheless it shouldberememberedthatabasicknowledgeofclinicalpathologyandpatho- physiologyisnecessarytounderstandthecausesoffailures.WethankStein- bach,Tos,Michaels,Behrendandmanyothersfortheirteachings.Twochap- tersdonotdirectlyfollowtheconceptofthisbook.Achapteronlasersurgery by an experienced specialist and a chapter on cartilage tympanoplasty were included because these techniques are under discussion at the present time andmaybeofimportanceinthefuture. Successful middle ear surgery, regardless of technique, requires intensive training on temporal bones, surgical training under the observation of an experiencedsurgeon,andpermanentcontinuouseducationuntilretirement. VIII Preface Conferences, workshops and visits to other centres are necessary. Surgical manualsprovideadditionalideas.Especiallywewanttomentiontheexcellent compilationofotosurgicaltechniquesbyMirkoTos. WeareverygratefultoHaraldKonopatzki,whoprovideduswiththeexcel- lentillustrationsinthisbook.Wewishalsotoexpressoursinceregratitudeto Dr.AndreGurrforhisexcellenthelpwiththeassemblyoftheDVD.Wealso thankthepublishersfortheirsubstantialhelp,supportandpatience. We hope that our book will serve as an aid to learning the techniques of middleearsurgeryandwillprovideasystematicandcomprehensiveapproach tothesubjectforallsurgeonsinvolvedinotologicsurgery. HenningHildmann,HolgerSudhoff Bochum,Germany Contents 1 SurgicalAnatomy A.Rauchfuss .................................................. 1 2 PreoperativeEvaluation J.Lautermann,H.Sudhoff,H.Hildmann ........................ 10 Audiology ...................................................... 11 Imaging ........................................................ 11 PatientInformation .............................................. 11 SignedConsent.................................................. 12 MedicalTreatment ............................................... 13 NerveMonitoringandComputer-AssistedSurgery ................... 13 3 WhenNotToDoSurgery H.Hildmann,H.Sudhoff ....................................... 14 4 PostoperativeTreatment H.Sudhoff,H.Hildmann ....................................... 15 5 LocalAnaesthesia H.Sudhoff,H.Hildmann ....................................... 17 GeneralAnaesthesia ............................................. 18 6 ApproachestotheMiddleEar A.Gurr,H.Sudhoff,H.Hildmann ............................... 19 TranscanalApproach ............................................. 19 EndauralApproach .............................................. 19 RetroauricularApproach.......................................... 20 TympanomeatalFlap ............................................. 22 7 HarvestingandProcessingofSoftTissues H.Sudhoff,H.Hildmann ....................................... 24 HarvestingCartilage ............................................. 26 PreparationofCartilage .......................................... 28 HarvestingPerichondrium ........................................ 29 8 ExternalEarCanalSurgery H.Hildmann,H.Sudhoff ....................................... 30 PostoperativeChanges............................................ 30 X Contents PostoperativeStenosis .......................................... 30 OtherPostoperativeChanges..................................... 32 Trauma......................................................... 33 FracturesIntotheMedialCranialFossa ........................... 34 Post-traumaticAtresia .......................................... 34 InflammationandSequelae ....................................... 34 PostinflammatoryStenosis ...................................... 34 NecrosisoftheFloorortheExternalAuditoryCanal................. 35 PostinflammatoryMeatalFibrosis ................................ 35 MalignantExternalOtitis ....................................... 35 IdiopathicChanges .............................................. 36 Exostosis ..................................................... 36 9 TympanicMembraneClosure H.Sudhoff,H.Hildmann ....................................... 38 TransmeatalApproach............................................ 38 CentralPerforations.............................................. 38 EndauralIncision .............................................. 39 HarvestingoftheGraft ......................................... 39 PreparationoftheSkinFlap ..................................... 40 Cartilage ....................................................... 42 10 CartilagePalisadeTympanoplasty M.Bernal-Sprekelsen .......................................... 44 SurgicalTechnique ............................................... 44 Evaluation ...................................................... 45 Results ......................................................... 45 Conclusions..................................................... 46 11 OssicularChainReconstruction H.Sudhoff,H.Hildmann ....................................... 49 12 MaterialsforOssicularChainReconstruction M.Yung ....................................................... 55 13 AntrotomyandMastoidectomy H.Sudhoff,H.Hildmann ....................................... 62 Definition ...................................................... 62 Indications ..................................................... 62 14 CholesteatomaSurgery H.Sudhoff,H.Hildmann ....................................... 67 Introduction .................................................... 67 GeneralPrinciplesforSurgery ..................................... 69 SurgicalSteps ................................................... 70 Contents XI 15 MastoidCavity H.Sudhoff,H.Hildmann ...................................... 73 Indications .................................................... 73 DefinitionofOpenandClosedTechniques ......................... 73 OpenCavity ................................................... 75 SurgicalSteps ................................................ 76 ReductionofVolume .......................................... 80 Meatoplasty.................................................. 81 ClosedTechniques .............................................. 81 IntactCanalWallTechnique .................................... 81 SurgicalSteps ................................................ 82 Obliteration.................................................. 88 Reconstruction ............................................... 91 FistulasoftheSemicircularCanals ................................ 92 Packing ....................................................... 93 16 SpecificInfections H.Sudhoff,H.Hildmann ...................................... 94 17 Complications J.Lautermann,H.Sudhoff..................................... 95 LabyrinthitisandFacialPalsy..................................... 95 ExtraduralComplications ........................................ 96 IntracranialComplications ....................................... 97 18 Tympanosclerosis H.Sudhoff ................................................... 98 19 TheAtelectaticEar H.Hildmann.................................................. 99 20 RevisionSurgery H.Hildmann,H.Sudhoff ...................................... 100 EarlyRevisions ................................................. 100 LateRevisions.................................................. 100 SpecialProblems ............................................... 101 21 FacialNerveSurgery O.Guntinas-Lichius,H.Sudhoff,H.Hildmann .................. 103 Indications .................................................... 103 FacialNervePalsyAfterTemporalBoneFractureandOtherTraumas ... 105 ApproachesforFacialNerveExplorationandDecompression ......... 106 TechniquesofFacialNerveReconstruction ......................... 107 IatrogenicLesionsDuringEarSurgery ............................. 110 PostoperativeCompletePalsyAfterEarSurgeryinPatientswithNormal PreoperativeFacialNerveFunction.............................. 110
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