- What is your prediction about post operative hearing levels? (Surprisingly, testing was not conducted soon after the operation.)
PATIENT: Y.D.
AGE: 5 years old
PREOPERATIVE DIAGNOSIS: Congenital left aural atresia
POSTOPERATIVE DIAGNOSIS: Congenital left aural atresia
DATE: 11/15/07
OPERATION: Repair of congenital left aural atresia with intraoperative facial monitoring
INDICATION FOR THE PROCEDURE: This is a 5-year-old female who was born with Crouzon disease. She has bilateral congenital aural atresia and has previously had a repair on the right ear. She has a complete bony canal stenosis and a conductive hearing loss in her left ear. A CT scan shows a well-ventilated left middle ear space. She is here now for surgery to repair the atresia. Her parents are aware of the complicated nature of the surgery as well as potential complications, including facial paralysis, permanent deafness, severe dizziness, alteration of taste, perforation, infection, as well as restenosis of the external canal.
OPERATIVE FINDINGS: The patient has a complete bony atresia of the left external auditory canal. There was a well-formed middle ear space with an intact ossicular chain that was mobile. There were definite irregularities of the ossicles, but there was continuity and the atresia plate was safely removed. A facial graft was used for the membrane, a skin graft was placed into the bony canal, and a large meatoplasty was created.
COMPLICATIONS: None. Intraoperative facial nerve monitoring was used throughout the procedure.
DESCRIPTION OF THE PROCEDURE: The patient was brought to the operating room and placed in the supine position, receiving general endotracheal anesthesia. Time was taken to identify the patient, the correct ear, and the operation to be performed. Four cc of 1% Xylocaine with 1:200,000 epinephrine were injected into the left external auditory canal meatus and postauricular area. The left ear was then prepped and draped in the normal fashion, and then facial monitor leads were inserted.
I used a Cottle elevator and a whirlybird elevator into the external canal to see if there was any lumen, but there was none. Therefore, a postauricular incision was made and the soft tissue was brought down to the area of the presumptive external auditory canal. Elevating the soft tissues revealed a complete bony plug where the external auditory canal would have been. The anesthesiologist was able to move the mandible so I could identify which the mandible was. At this point, I removed an extensive piece of conchal cartilage for a later meatoplasty. I also harvested a piece of temporalis fascia, which was pressed and dried for later use. A self-retaining retractor was inserted. Looking at the bony plug filling the external auditory canal, I drilled just posterior to the tympanic ring in the presumptive area of the dural plate superiorly. I initially did this with a 4mm cutting bur with continuous suction irrigation. Drilling medially, I was able to identify the dura, which was left undisturbed, and proceeded to drill medially, thinning the bone anteriorly, but not entering into the TMJ. Further drilling medially revealed the atresia plate without any difficult. There was pneumatization around this. I removed the superior portion of the atresia plate and was able to identify the malleus, which was mobile. I continued and delicately removed the rest of the atresia plate and was able to separate the atresia plate from the ossicles. There was a nicely ventilated middle ear. I was able to remove this anteriorly and interiorly. This revealed in the middle ear the presumptive chorda tympani as well as stapedial tendon and there was no aberrant facial nerve. The ossicular chain was not normal. The malleus was essentially normal; however, the incus was visualized and there was an area of the incudostapedial joint that was surrounded by some fibrous tissue, but I was not able to clearly see just the stapes. However, there was excellent mobility and I did not want to risk further dissection of any soft tissue around the stapes as all the bony interference was removed so that there was complete mobility of the ossicular chain with gentle palpation of the malleus. I made sure to widen the canal so that there was space posterior to the incus and stapes interiorly. Once this was performed, the middle was packed off with Gelfoam pledgets soaked in adrenaline 1:10,000 for hemostasis.
At this point, I began the reconstruction. The previously harvested fascia was introduced into the midline ear after I made an incision to accommodate the malleus. This was easily positioned with the fascia then placed against the bone of the canal anteriorly, inferiorly, posteriorly, and superiorly. It extended only slightly laterally. It was fixed so that it was placed just slightly medial to the malleus and then the edges were placed so that it covered the rest of the malleus. Hopefully this prevented any lateralization of the graft. Following this, the temporalis fascia was packed off with Gelfoam pledgets soaked in Floxin drops.
I had previously removed a piece of skin from the posterior portion of the posterior skin edge. I thinned that, getting rid of all the subcutaneous tissue. I then introduced that into the middle ear in 3 different places to align the bony external auditory canal. Once this was positioned, I placed the edges of latex glove to prevent adhesions with the soft tissue to be removed, hopefully keeping the skin graft applied down to the bone. Following this, I placed in an ear wick and more Floxin drops, and then released the retractors. The postauricular incision was then closed in 2 layers with a 3-0 chromic subcutaneous layer and a 4-0 Monocryl running subcuticular layer. I had also placed some sutures along the meatal skin to keep it wide open. Following this, two pieces of Xeroform gauze were applied to the skin posteriorly and then a bulky mastoid dressing was applied.
There were no complications.