We do not have access to information about her hearing loss amount preoperatively for this case, other than what is summarized below, and we don’t know what, if any, amplification she has received. Below is the operative report transcript.
- Before looking at the next page, guess as to the degree of hearing loss given the report of the surgery.
PATIENT: Y.D.
AGE: 5 years old
PREOPERATIVE DIAGNOSIS: Congenital right aural atresia
POSTOPERATIVE DIAGNOSIS: Congenital right aural atresia
DATE: 01/29/07
OPERATION: Repair right congenital aural atresia with split-thickness skin graft and intraoperative facial nerve monitoring
INDICATION FOR THE PROCEDURE: This is a 5-year-old child who was born with Crouzon disease. She has a right ear canal stenosis and a maximal conductive hearing loss. A CT scan showed a pneumatized mastoid and middle ear space with an atretic plate and the plan was to operate on the ear to try to improve the hearing and create an ear canal. The nature of the operation was discussed in detail with the parents, including the incision behind the ear as well as the use of a possible skin graft and the use of intraoperative facial nerve monitoring. The risks of the operation, including facial paralysis, total sensorineural deafness, severe dizziness, ringing of the ear, alteration of taste, and infection were all discussed.
OPERATIVE FINDINGS: Patient had a complete bony stenosis of the right external auditory canal. She had a well-pneumatized middle ear and epitympanum; however, there was no ossicular chain that could be identified. In addition, I could not be sure where the oval window was; therefore no prosthesis was put into the middle ear. The tympanic membrane was reconstructed with a thin auricular cartilage, a split-thickness graft was placed into the external auditory canal, and a meatoplasty was performed. Intraoperative facial nerve monitoring and intraoperative facial nerve stimulation was used. There was no evidence of any facial nerve injury.
DESCRIPTION OF THE PROCEDURE: Patient was brought to the operating room, placed in supine position, receiving general endotracheal anesthesia. 4 mL of 1% Xylocaine with 1:100,000 epinephrine were injected into the right ear canal meatus, as well as into the postauricular area. Some of the hair behind the right ear was shaved. The facial nerve monitor leads were attached and the right ear was prepped and draped in the normal sterile fashion. I initially placed a Cottle elevator into the meatus; however, it was essentially a blind opening. It did not show any evidence of a formed bony canal. Following this, a postauricular incision was then made and the soft tissues and auric were elevated until I found the area of the external auditory canal. It was filled with an atretic type of bone. There was a pneumatized mastoid bone just posterior to this. I had the anesthesiologist manipulate the mandible to identify the location of the mandible, which was in front of this atretic bone. Using the operating microscope, and 3-mm and 4-mm diamond burs, the atretic bone was drilled away progressively medially. The tegmen was thinned superiorly. As I proceeded medially, I identified the atretic plate at its medial edge and was able to identify the pneumatized epitympanum area. I did not lower the canal wall and did not violate the mastoid bone. At this point, I identified the medial atretic bone and drilled it away, completing the exposure of the middle ear space. The TMJ was thinned anteriorly inferiorly. The Eustachian tube orifice was identified. I did not find any vascular abnormalities; however, I could not see any actual ossicles, nor could I adequately identify the round or oval window niche. Unfortunately, because of this, I did not feel that there was any ability to place in a middle ear prosthesis. I used the facial nerve stimulator at a setting of 0.3 mA to see if there was any evidence of facial nerve dehiscence. I did not hear anything or see anything abnormal to suggest that. At this point, we had a well-formed ear canal and middle ear space. There was no sign of any infection or any other disease. I lined the middle ear with Gelfoam pledgets. I then took the cartilage I had previously harvested and thinned it and used it to create a tympanic membrane. This was properly positioned, and then some pledgets of Gelfoam with Floxin drops were placed on top of this. I retrieved a piece of skin from the postauricular area and I thinned it and was then able to use a few pieces to line the bony external auditory canal and prevent shift or extrusion of the split-thickness skin graft. Once this was properly positioned, I placed an ear wick into the external canal with more Floxin drops. The retractors were then released. I made a large meatoplasty incision and sutured those flaps superiorly and inferiorly creating a nice wide meatus. The postauricular incision was then closed in 2 layers with #3-0 chromic subcutaneous layer and a #4-0 Monocryl running subcuticular layer. I was able to see the ear wick in the external auditory canal. At this point, Steri-Strips were applied posteriorly and then a bulky mastoid dressing was applied.
There were no complications. Patient does have the possibility of wearing a hearing aid in the future, as I do not think that her hearing will improve significantly from this surgery.