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Myringoplasty and Tympanoplasty

Introduction Myringoplasty and tympanoplasty are surgical procedures designed to address pathology of the tympanic membrane and the middle ear, respectively. Both procedures restore the integrity of a perforated tympanic membrane, while tympanoplasty also addresses pathology in the middle ear, such as chronic infection, cholesteatoma, or ossicular chain problems. This most often implies and requires raising a tympanomeatal flap to facilitate middle ear manipulation. Zollner and Wullstein…

Intracranial Complications of Otitis Media

Introduction Complications from acute otitis media or chronic otitis media can be divided into extracranial complications (i.e., facial nerve paralysis, labyrinthitis, and subperiosteal abscess) and intracranial complications. Intracranial complications of otitis media include meningitis, epidural abscess, subdural abscess (empyema), brain abscess, lateral sinus thrombophlebitis/sigmoid sinus thrombosis, otitic hydrocephalus, and Gradenigo’s syndrome ( Fig. 130.1 ). On occasion, an intracranial complication may be the initial symptom in…

Otitis Media, Myringotomy, Tympanostomy Tube, and Balloon Dilation

Introduction Otitis Media Acute otitis media (AOM) and chronic otitis media with effusion are conditions well known to all otolaryngologists. Infants are predisposed to otitis media because of their immune-compromised state and altered angulation of the eustachian tube (ET). Later in life, adenoid enlargement with ET obstruction may also play a role. Children with craniofacial and cleft palate disorders are also more likely to develop otitis…

Keratosis Obturans and Canal Cholesteatoma

Introduction Keratosis obturans (KO) and external auditory canal cholesteatomas (CC) are uncommon diseases of the external auditory canal that share the common characteristic of a buildup of desquamated keratin in the ear canal. Since the 19th century, KO and CC have been considered variants of the same disease until 1980, when Piepergerdes et al. classified these diseases as separate entities, often requiring distinct management plans. Distinguishing between…

Osteomas and Exostoses of the External Auditory Canal

Introduction Osteomas and exostoses are benign bone growths found in the temporal bone, most commonly in the bony external auditory canal (EAC). The structure of the EAC takes a tortuous route from the external auditory meatus to the tympanic membrane (TM), through the cartilaginous lateral third to the medial bony two-thirds. The S -shaped structure of the canal provides a protective mechanism to the TM. The…

Foreign Bodies of the External Auditory Canal

Introduction The acute event resulting from entrapment of a foreign body in the ear canal will bring most patients to the attention of a physician, physician’s assistant, or nurse practitioner. Patients may be treated in a variety of settings including an emergency room, clinic, or office. It is important to note that different age- and gender-specific patterns emerge in describing the specific types of foreign bodies…

Office-Based Procedures in Otology

Introduction In the practice of otology, the various surgical procedures extend along a spectrum from the clinic to the operating room. The procedures performed in the clinic recapitulate the same surgical techniques used in the operating room. For this reason, the process of refining one’s surgical techniques begins in the clinic. The methodology, preparation, and calming bedside manner while performing procedures in the clinic can lead…

Reconstruction After Skull Base Surgery

Introduction Over the past 15 years, significant improvements in surgical techniques coupled with technological advancements have led to the ability to remove complex skull base tumors using endoscopic endonasal surgery (EES). EES is applicable for a wide variety of surgical pathology, including everything from sinonasal cancers to intradural primary brain tumors. When EES was first developed, proper repair of the skull base and prevention of subsequent…

Transnasal and Transoral Approaches to the Cervical Spine

Introduction The superior aspects of the cervical spine (C1 and C2) and the craniovertebral junction are difficult to access via a transcervical approach. Traditionally, a transoral/transpalatal approach has been used, but is associated with significant morbidity. With the advent of endoscopic techniques, a transnasal approach may be used with improved visualization and avoidance of the morbidity associated with a transoral approach. For lesions that require access…

Juvenile Angiofibroma

Introduction Juvenile angiofibroma (JNA) is a rare, benign tumor that is found almost exclusively in adolescent males. The pathogenesis of JNA remains undefined, although hormonal and genetic factors have been implicated. JNA arises in the lateral nasopharynx near the sphenopalatine foramen and can spread in multiple directions to the nasal cavity, oropharynx, paranasal sinuses, orbit (via inferior orbital fissure), and infratemporal fossa (via pterygomaxillary fissure). Intracranial…

Surgical Approaches to the Infratemporal Fossa

Introduction A variety of surgical approaches to the infratemporal fossa (ITF) have been developed to address pathologies in specific areas while attempting to preserve the function of key neurovascular structures. Indeed, intimate knowledge of the anatomy and a multidisciplinary evaluation are of foremost importance when considering a surgical approach to this complex area. The boundaries of the ITF are shown in Table 121.1 . Tumors may…

Endoscopic Petrosal Approaches

Introduction The petrous portion of the temporal bone is a pyramid-shaped bone wedged between the greater wing of the sphenoid and the occipital bone. Its base is composed of the bony labyrinth (semicircular canals and cochlea); its anterosuperior surface makes up a large portion of the floor of the middle cranial fossa; its posterosuperior surface forms the anterolateral wall of the posterior cranial fossa; and its…

Endoscopic Endonasal Transpterygoid Approaches to the Middle Cranial Fossa

Introduction Endoscopic endonasal approaches (EEAs) provide direct access to pathologies near the median and paramedian ventral skull base. A major principle of endoscopic endonasal surgery is the use of anatomical corridors to safely access skull base lesions with low associated morbidity. To access the middle cranial fossa, the maxillary sinus and the pterygopalatine fossa (PPF) are traversed to encounter and remove the pterygoid process, partially or…

Transcranial and Endonasal Approaches to the Anterior Cranial Base

Introduction Surgery of the anterior cranial base is often fraught with anxiety and concern because of the close proximity of major neurovascular structures. Often these tumors are extracranial; however, when tumors extend intracranially or invade into the brain parenchyma, a team effort of Neurosurgeons and Otolaryngologists is needed for surgical management. Most lesions of the anterior cranial base arise from the nasopharynx, nasal cavity, or paranasal…

Endonasal Approach to the Sella and Parasellar Areas

Video 117.1 , Video 117.2 , Video 117.3 , Video 117.4 , Video 117.5 , Video 117.6 , Video 117.7 , Video 117.8 , Video 117.9 , Video 117.10 , Video 117.11 Surgery of the central cranial base has evolved over the past several decades from open transcranial or transfacial approaches that require significant retraction or disruption of normal anatomy, to endoscopically assisted approaches that maintain…

Endoscopic Management of Cerebrospinal Fluid Leaks

Introduction A cerebrospinal fluid (CSF) leak defines a fistula between the subarachnoid space and the sinonasal tract. Patients with CSF leaks present with symptoms such as clear nasal discharge and headache or complications such as pneumocephalus, meningitis, or brain abscess. The main indication for repairing a CSF leak is to prevent these potentially life-threatening complications. CSF leaks can be classified in a number of ways; etiology…

Frontal Sinus Cranialization

Introduction The first description of frontal cranialization was in 1978 by Donald and Bernstein. It consists of meticulous removal of the mucosa of the frontal sinus, eliminating the posterior wall of the sinus and allowing the frontal lobe to come to rest against the anterior table of the frontal sinus. Historical Perspective The concept of cranialization came from the evolution of treatment of extensive wounds in…

Osteoplastic Obliteration of the Frontal Sinus

Introduction In the preendoscopic era, the osteoplastic flap procedure was the accepted method of management of frontal sinusitis. Initial approaches described in the late 19th century (e.g., the Reidel procedure) conceptualized the complete exenteration of the sinus, including the anterior wall, which of course resulted in a significant cosmetic deformity, reserved for only the most severe disease processes. The more modern osteoplastic obliteration (using abdominal adipose…

Draf III, Endoscopic Modified Lothrop

Introduction Chronic frontal sinusitis continues to be a challenge to treat both medically and surgically. Despite the advances in endoscopic sinus surgery, the wide variety of surgical options necessary for treatment of frontal sinusitis speaks to the difficult nature of managing disease in this location. Refractory frontal sinusitis in particular has challenged sinus surgeons for years. In the early 1900s, ablation of the frontal sinus by…

Endoscopic Approach to the Frontal Sinus

Introduction The endoscopic approach to the frontal sinus is predicated on understanding the anatomy of the frontal recess. The frontal sinus outflow tract is dependent on the anatomic relationships of various structures, including the uncinate process, middle turbinate, agger nasi, and frontoethmoid cells. Most commonly, the uncinate process ascends from its inferior and anterior attachments to the inferior turbinate and lacrimal bone, respectively, to blend in…