Table Of ContentH.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
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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
