The application of minimally-invasive approaches in otologic surgery, including the management of middle ear tumors like glomus tympanicum tumors, represents a promising advancement in the field, potentially improving surgical outcomes and patient recovery. In this article, a patient with pulsatile tinnitus is found to have a glomus tympanicum tumor of the right ear. Calhoun Cunningham III, MD performs a transcanal resection of the mass using the KTP laser.
Temporal Bone Dissection (Cadaver) Cameron M. A. Crasto1; C. Scott Brown, MD2 1University of Toledo College of Medicine 2University of Miami Miller School of Medicine
Temporal bone dissections are a critical learning tool for otologic/neurotologic surgery. The “Temporal Bone Dissection Manual” from the House Institute has long served as a ‘gold standard’ for the stepwise demonstration of this process. In this video, a progressive step-by-step dissection of the temporal bone is performed. Key anatomical structures and landmarks and outlined, and their physiological importance in the context of different otologic pathologies is explained. The procedure begins with the identification of soft tissue landmarks and surface anatomy before delving into cortical mastoidectomy and facial nerve identification. The mastoid tip region is discussed, before moving on to describe the tegmen and endolymphatic sac. A facial recess dissection is performed and middle ear anatomy is explained. A labyrinthectomy and exposure of the internal auditory canal conclude the dissection. In addition to going over the anatomy of the temporal bone dissection, a discussion of how to execute these procedures safely and efficiently is conducted.
By having a thorough understanding of the anatomy of the temporal bone, medical students, residents, and fellows are better able to understand the reasoning behind different otologic procedures and how they can be used to treat patients. This demonstration was created to inform and teach residents and medical students about temporal bone anatomy.
Mastoidectomy David M. Kaylie, MD, MS1; Adam A. Karkoutli2; C. Scott Brown, MD1 1Duke University Medical Center 2Louisiana State University Health Sciences Center – New Orleans
Mastoidectomy involves the removal of bone and air cells contained within the mastoid portion of the temporal bone. Common indications for this procedure include acute mastoiditis, chronic mastoiditis, cholesteatoma, and the presence of tympanic retraction pockets. Mastoidectomy may also be performed as part of other otologic procedures (e.g. cochlear implantation, lateral skull base tumors, labyrinthectomy, etc.) in order to gain access to the middle ear cavity, petrous apex, and cerebellopontine angle.
The procedure involves dissecting within the confines of the mastoid cavity, which include the tegmen superiorly, the sigmoid sinus posteriorly, the bony ear canal anteriorly, and the labyrinth medially. Mastoidectomy is traditionally classified as: simple (cortical/Schwartze), radical, and modified radical/Bondy’s mastoidectomy. The procedure can also be classified based on the preservation of the posterior canal wall: canal wall up (CWU) or canal wall down (CWD).
Cochlear Implant C. Scott Brown, MD; Calhoun D. Cunningham III, MD Duke University Medical Center
For patients who present with bilateral severe-to-profound sensorineural hearing loss who have little-to-no benefit from conventional hearing aids, cochlear implants can restore hearing by directly stimulating the cochlear nerve.
This video demonstrates the placement of a cochlear implant. A standard mastoidectomy and facial recess approach is performed to visualize the round window niche and membrane. The round window membrane is opened, and the cochlear implant electrode is carefully inserted into the scala tympani. After several weeks, the patient returns for implant activation with a dedicated team of audiologists.
Otosclerosis can lead to progressive conductive hearing loss, significantly affecting quality of life. For patients who choose surgery, the tympanic membrane is elevated, and the middle ear space is explored. If the surgeon confirms that the stapes is fixed in the oval window, either a stapedotomy or stapedectomy can be performed.
In the stapedotomy, the surgeon removes the stapes superstructure, creates a fenestration in the footplate, and places a prosthesis from the incus through the fenestration into the vestibule. In this instance, the patient was able to regain nearly all of the hearing that had been lost as a result of stapes fixation.
Endolymphatic sac (ELS) decompression can be performed for patients with Meniere’s disease who have failed conservative treatment such as dietary changes and medical therapy. The full pathophysiological mechanisms that result in Meniere’s disease are not entirely understood. The variation in techniques for performing ELS decompression support this; there is no concrete data to justify one approach over another. Regardless, in the correct patient, ELS decompression can significantly alleviate the patient’s symptoms. To do so, a mastoidectomy is performed to expose the bony labyrinth as well as the bone overlying the sigmoid sinus. Decompression of the sac can be accomplished by removing overlying bone, incising the dura, or stenting the dura open.
C. Scott Brown, MD Neurotology & Lateral Skull Base Surgery Fellow University of Miami Miller School of Medicine
Michael E. Hoffer, MD Professor of Otolaryngology and Neurological Surgery University of Miami Miller School of Medicine
Endoscopic ear surgery can improve visualization of critical structures. In this video, Dr. Scott Brown performs an endoscopic stapedectomy for the treatment of conductive hearing loss. He explains his technique and the advantages afforded by adoption of the endoscope in ear surgery.
C. Scott Brown, MD Neurotology & Lateral Skull Base Surgery Fellow University of Miami Miller School of Medicine
Cadaveric dissections of the temporal bone are a critical part of learning otologic surgery in residency. Dr. Scott Brown, neurotology fellow at the University of Miami, performs a step-by-step dissection of the temporal bone. He outlines key anatomical structures and describes safe and efficient techniques for these procedures.
David M. Kaylie, MD, MS
Department of Surgery
Division of Head and Neck Surgery & Communication Sciences
C. Scott Brown, MD
Resident Physician
Division of Head and Neck Surgery & Communication Sciences
A patient with eustachian tube dysfunction and a history of multiple pressure equalization tubes presents to an otolaryngology clinic with complaints of hearing loss. Her eardrum was found to be hyperinflated on exam. Dr. David Kaylie demonstrates a myringoplasty technique using a CO2 laser, along with placement of a tympanostomy tube.
Calhoun D. Cunningham III, MD
Head and Neck Surgery & Communication Sciences
Duke University
C. Scott Brown, MD
Resident Physician
Head and Neck Surgery & Communication Sciences
Duke University
A patient with multiple prior surgeries continued to have persistent drainage and a perforated ear drum. In this video, Dr. Cunningham demonstrates a methodical approach to revision tympanoplasties for these challenging patients.
