Clinical-histopathological correlations of pitfalls in middle ear surgery

Case report: inadvertent carotid artery injury during myringotomy as a result of carotid artery dehiscence

We report the case of a 3-year-old girl whose internal carotid artery was pierced during a myringotomy. Postoperative computed tomography demonstrated that the complication was caused by a dehiscent carotid canal wall; contralateral dehiscence was also present. The patient had previously received two sets of middle ear ventilation tubes with no complications. This article addresses the epidemiology and anatomy of carotid dehiscence, and discusses methods to potentially prevent this complication, including screening and imaging modalities.

Surgery of the ear and the lateral skull base: pitfalls and complications

Surgery of the ear and the lateral skull base is a fascinating, yet challenging field in otorhinolaryngology. A thorough knowledge of the associated complications and pitfalls is indispensable for the surgeon, not only to provide the best possible care to his patients, but also to further improve his surgical skills. Following a summary about general aspects in pre-, intra-and postoperative care of patients with disorders of the ear/lateral skull base, this article covers the most common pitfalls and complications in stapes surgery, cochlear implantation and surgery of vestibular schwannomas and jugulotympanal paragangliomas. Based on these exemplary procedures, basic "dos and don'ts" of skull base surgery are explained, which the reader can easily transfer to other disorders. Special emphasis is laid on functional aspects, such as hearing, balance and facial nerve function. Furthermore, the topics of infection, bleeding, skull base defects, quality of life and indication for revision surgery are discussed. An open communication about complications and pitfalls in ear/lateral skull base surgery among surgeons is a prerequisite for the further advancement of this fascinating field in ENT surgery. This article is meant to be a contribution to this process.

Dehiscent high jugular bulb: a pitfall in middle ear surgery

OBJECTIVE

The aim of this study was to present our experience on facing the dehiscent high jugular bulb (HJB) during middle ear surgery in the past 2 decades.

STUDY DESIGN

Retrospective review.

SETTING

Secondary referral hospital.

PATIENTS

From January 1982 to June 2002, consecutive 1,657 patients underwent surgical intervention for middle ear cleft diseases, a total of 1,857 operations. Of them, 10 ears (0.5%) in nine patients were proven to have dehiscent HJB during operation for adhesive otitis media in four ears and for chronic otitis media with cholesteatoma in six ears.

MAIN OUTCOME MEASURES

Each patient underwent otoscopic examination, radiographic examination, and audiometry before and 6 months after operation.

RESULTS

Otoscopic examination revealed atrophic changes in the pars tensa with adhering to the promontory in two ears, attic retraction in one ear, and both findings in seven ears. All lesions were located beneath the basal turn of the cochlea and the round window niche at anteroinferior and/or posteroinferior quadrants. Active bleeding was encountered in two ears (20%) while elevating the tympanomeatal flap, which was treated by pressure compression associated with gelfoam sheet, then covered with an autologous cartilage to protect the dehiscent bulb. For the remaining eight ears, the bulbs were reinforced with fascia, perichondrium, or autologous cartilage. All 10 ears were allowed completion of the planned surgery without complications.

CONCLUSION

HJB is not a contraindication for middle ear surgery. Awareness of this pitfall may lessen the operation risk.

[Acute complications during middle ear surgery: part 1: Problems during tympanoplasty--what to do?]

Due to the unusual anatomical situation in the middle ear, there are a variety of possible complications that may occur during tympanoplasty. Dislocation of the ossicular chain with and without opening of the labyrinth, injuries to the facial nerve and hemorrhage from large arteries and veins may occur. Adequate management of these complications is necessary in order to avoid further damage for the patient. The first question in case of an acute complication is always whether it is possible to stop the operation. It is also important to determine the time to react, e.g. if an injury of the facial nerve is assumed, when a revision needs to be performed. It also should be considered to refer the patient to a colleague who is not as emotionally involved in the case as the primary surgeon.

The flexible endaural tympanoplasty: pathology-guided, pathogenesis-oriented surgery for the middle ear

The flexible approach to tympanoplasty has been found to be adaptable to various forms of pathologic conditions found in the temporal bone, including inflammation and infection, congenital stenosis, benign and malignant tumors, and traumatic injuries. This approach finds its best indication among all pathologic conditions in the temporal bone, in the surgical treatment of otitis media, and its sequelae. A procedure conceived to treat this dynamic process must be adaptable to new circumstances and new findings and be ready to manage unexpected situations. The flexible tympanoplasty is a step-wise approach designed to explore the contents of the middle ear methodically and in the process disclose, confirm, and often treat disease.