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Surgery of the Endolymphatic SAC

Acknowledgment We thank Mark D. Packer, MD and D. Bradley Welling, MD, authors of this chapter in previous editions. Please access Videos to view the corresponding videos for this chapter. Introduction The endolymphatic sac is an important organ in maintaining fluid homeostasis within the inner ear system. Alterations in this process can result in a state of endolymphatic hydrops (ELH). Ménière disease (MD), a clinical syndrome…

The Bone-Anchored Cochlea Stimulator—BACS

Please access Videos to view the corresponding videos for this chapter. The Bone-Anchored Cochlea Stimulator (BACS) systems are based on the concept of direct bone conduction stimulation of the cochlea. The original BACS system, the Baha, combines an osseointegrated implant and a percutaneous abutment ∗ ∗ The terms implant and abutment are interchangeable, as are abutment and coupling . placed behind the external ear with a…

Implantable Hearing Devices

It is estimated that 32 million Americans have a hearing loss severe enough to cause problems with communication. The severity of this loss ranges from mild, in which the individual may have difficulty only when significant background noise is present, to profound, in which even in the quietest situation the patient is unable to understand and communicate. Most hearing loss is sensorineural in nature, and less…

Surgery for Cochlear Implantation

Please access Videos to view the corresponding videos for this chapter. The advances seen in cochlear implantation have been nothing short of remarkable. Although the first attempt to stimulate the auditory system electrically occurred over two centuries ago, the development of a cochlear prosthesis to restore hearing to patients with sensorineural hearing loss (SNHL) has happened only over the past six decades. The early pioneering work…

Facial Nerve Tumors

Please access Videos to view the corresponding videos for this chapter. Overview Background Tumors of the facial nerve are rare causes of facial paralysis. The two most common tumors are facial nerve schwannomas (FNS), which are intrinsic to the nerve, and facial nerve hemangiomas, or geniculate ganglion hemangiomas (GGH), which are extraneural in origin. This chapter focuses on these two types of facial nerve tumors. Much…

Traumatic Facial Paralysis

The facial nerve may be injured by blunt and penetrating mechanisms. Common causes include motor vehicle accidents, stab or gunshot wounds to the face, and iatrogenic injuries during head, neck, and temporal bone surgical procedures. The primary mechanisms of injury to the facial nerve include traction, compression, and transection of the nerve. The course of the nerve from the brainstem to the facial musculature can be…

Management of Bell’s Palsy and Ramsay Hunt Syndrome

Of the multitude of causes of facial paralysis, Bell’s palsy and Ramsay Hunt syndrome are two of the most common. Bell’s palsy alone accounts for almost three-quarters of all acute facial palsies. Although the diagnosis of Ramsay Hunt syndrome is generally obvious, a thorough evaluation and close follow-up are required to establish a firm diagnosis of Bell’s palsy. This chapter discusses the pathology, pathophysiology, epidemiology, evaluation,…

Perilymph Fistula: Otic Capsule Defects Not Seen with Imaging

If you listen carefully to the patient, they will tell you the diagnosis. William Osler Arguably, perilymph fistula (PLF) is the single most polarizing diagnosis in our specialty. As a resident at UCLA, I was taught that PLFs do not exist. This was ironic, because only a generation before, UCLA’s Victor Goodhill was one of the thought leaders in the pathophysiology of PLF ( Fig. 25.1…

Special Problems of Otosclerosis Surgery

Please access Videos to view the corresponding videos for this chapter. As the incidence of otosclerosis declines, fewer surgeons acquire adequate experience in stapes surgery, and even fewer surgeons treat the problems of either complicated or unsuccessful stapedectomy. This chapter presents a comprehensive approach and diagnostic criteria for the selection of these unusual patients. Intraoperative problems and solutions are defined and illustrated. The solutions are presented…

Partial Stapedectomy

History In 1958, Shea advocated total stapes footplate removal when using the polyethylene strut prosthesis and a vein graft to seal the oval window. Shortly thereafter, Schuknecht advocated the use of a wire and fat prosthesis, and House and Greenfield later advocated the use of a wire with absorbable gelatin sponge (Gelfoam) prosthesis. The use of a wire with Gelfoam or a wire-fat prosthesis necessitated total…

Laser Stapedotomy

Please access Videos to view the corresponding videos for this chapter. The surgical treatment of otosclerosis has been evolutionary in nature. Multiple techniques are now available to accomplish the same goal, which is illustrated by the number of chapters devoted to this subject in this book. The small-fenestra technique evolved as a less invasive method to accomplish stapedectomy. It allows a smaller opening into the inner…

Dural Herniation and Cerebrospinal Fluid Leaks

Please access Videos to view the corresponding videos for this chapter. An encephalocele occurs when the brain tissue herniates through a dural defect of the skull. Temporal bone encephaloceles manifest either as a mass or cerebrospinal fluid (CSF) in the middle ear, mastoid, or both ( Figs. 21.1 and 21.2 ). Encephaloceles have also been called dural herniations, brain herniations, brain prolapse, and meningoencephalocele. They have…

Complications of Surgery for Chronic Otitis Media

Acknowledgments We would like to thank Steven Harvey for his work on previous editions of this chapter. Please access Videos to view the corresponding videos for this chapter. Chronic otitis media is a formidable challenge to the otologist. Competent management requires a solid understanding of the temporal bone anatomy and the subtleties of the disease. It is ideal to avoid complications, so one should begin with…

Endoscope-Assisted Tympanomastoidectomy for Cholesteatoma

Historical Context of Otoendoscopy While Mer et al. and Nomura et al. reported passing fiberoptic and rigid endoscopes through tympanic membrane perforations in 1967 and 1982, respectively, endoscopic and endoscope-assisted otologic surgery did not catch on until the 1990s through the reports of several largely international surgeons who have since formed the International Working Group on Endoscopic Ear Surgery (IWGEES). The group “aims to develop the method of…

Tympanoplasty: Staging and Use of Plastic

Acknowledgment James Sheehy, MD (deceased), was the primary author for earlier versions of this chapter. His previous contributions to this work include the dominant surgical philosophy contained in the current version. Elimination of the disease and restoration of function are the two aims of tympanoplasty. In most teaching situations, one can separate the two aims, limiting the discussion to one or the other. However, the staging…

Mastoidectomy: Canal Wall-Down Procedure

Please access Videos to view the corresponding videos for this chapter. There are two approaches to mastoidectomy in patients with cholesteatoma and chronic otitis media. The canal wall-up (also known as intact canal wall) technique is discussed in detail in Chapter 16 . This chapter describes the technique for canal wall-down surgery. The related topics discussed in this chapter include the role of atticotomy and inside-out…

Mastoidectomy: Intact Canal Wall Procedure

Please access Videos to view the corresponding videos for this chapter. Mastoidectomy can be performed in two ways in cases of cholesteatoma. The canal wall-down technique is discussed in Chapter 17 . This chapter addresses the canal wall-up, or intact canal wall, technique. When James Sheehy, MD taught residents and fellows, he would emphasize that the call wall is intact, rather than “up.” The canal wall…

Surgery of Acute Infections and Their Complications

Definition and Clinical Significance Infections of the mastoid or middle ear may spread beyond the confines of the pneumatized spaces of the temporal bone. When this occurs, the patient is at risk for significant morbidity or mortality. While these complications were more common before the antibiotic era, the potential harm to the patient is high, and the presentation may be subtle. The complications of acute or…

Canal Wall Reconstruction Tympanomastoidectomy

Please access Videos to view the corresponding videos for this chapter. The primary goal in the surgical management of chronic otitis media with cholesteatoma is the creation of a dry, safe ear through removal of disease and alteration of anatomy to prevent recurrence. This goal can be accomplished effectively with preservation [canal wall-up (CWU)] or removal [canal wall-down (CWD)] of the posterior canal wall (PCW), both…

Ossicular Reconstruction

Please access Videos to view the corresponding videos for this chapter. Reconstruction of the middle ear sound-transformer mechanism has continued to evolve since the pioneering efforts of Wullstein and Zöllner in the 1950s. Despite improvements in materials and refinements in surgical techniques, complete closure of the air-bone gap on a consistent basis has proven elusive. The excellent hearing results consistently obtained with stapedectomy procedures are not…