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Chapter 107
Offi ce-Based Procedures in Otology 1089
PREOPERATIVE PLANNING
A complete otoscopic examination and an audiogram
showing evidence of conductive hearing loss should be
done before endoscopy. A computed tomography scan
may also be useful to evaluate the presence and extent
of cholesteatoma, as well as to attempt to evaluate the
integrity of the ossicular chain. If the TM is already
perforated, the perforation should be used for the
endoscopy; if not, a myringotomy “kit” is used. A full
set of endoscopes should be available because the
optimal angle required to evaluate middle ear struc-
tures will change, depending on placement of the tym-
panostomy window. Currently 0-, 30-, and 90-degree
Olympus endoscopes are available with an outer diam-
eter of 1.7 mm. Storz 30- and 70-degree endoscopes
with an outer diameter of 1.9 mm are also available.
The success of endoscopy in the offi ce hinges on
good communication with the patient before and
during the procedure. The patient should be aware that
A
B
C
D
Figure 107-9. Insertion of a pressure equalization tube. A, A thick mucoid effusion is noted in the right middle ear. B, Phenol is applied in
radial fashion in the posteroinferior quadrant. C, The myringotomy has been performed. D, A Paparella II tube has been inserted.

1090
Section 12
Otology
it is imperative for the head to remain still when the
endoscope is in use. Patients also need to be informed
that they may experience discomfort from palpation of
middle ear structures and that heat from the endoscope
light can induce vertigo. Patients should be informed
that at any point during the procedure they can ask to
stop or pause it and the endoscope will be removed
immediately; otherwise, the patient may be more likely
to move while the endoscope is in place, thereby causing
more damage.
SURGICAL TECHNIQUE
The patient is placed supine with the head tilted toward
the unaffected side and positioned at a height at which
the physician is comfortable and able to steadily maneu-
ver the endoscope. The ear is examined, and any
obstructing cerumen or debris is cleared. No anesthesia
of the eardrum is required if there is a concomitant TM
perforation of 2 mm or greater, thereby allowing easy
passage of the endoscopes. Otherwise, for both very
small perforations and intact TMs, appropriate local
anesthesia of the eardrum should be obtained in the
posterosuperior quadrant. An arc incision is then made
between the oval and round windows. The incision
should be large enough to allow passage of the endo-
scopes. Alternatively, a laser myringotomy may be made
in this location.
The endoscope is inserted into the ear canal and
advanced slowly toward the myringotomy. It is held at
the edge of the myringotomy, and when necessary, the
scope is advanced through the opening. The endoscopy
is begun with a 0- or 30-degree scope to obtain a feel
for proper positioning of the endoscope through the
opening. It is diffi cult to visualize straight ahead with a
70- or 90-degree scope, thus making it diffi cult to accu-
rately advance the scope to the opening. The choice of
scope is dependent on the position of the myringotomy,
as well as the patient’s anatomy. Through the standard
posterosuperior myringotomy, a 0- or 30-degree scope
should be able to visualize the stapes and part of the
incus, but a larger angle is generally needed to evaluate
the remainder of the chain (Fig. 107-10).
The status of the middle ear mucosa is
evaluated with particular attention paid to signs of
cholesteatoma. The integrity of the ossicular chain
is then closely examined for signs of otosclerosis,
dislocation, deformation, or other abnormality. In a
very cooperative patient, the ossicles may be palpated
by passing a pick through the myringotomy under
endoscopic visualization. The endoscope is held in
place with the nondominant hand and is used to guide
the pick to the myringotomy by sliding the tip of
the pick down the barrel of the endoscope until it
can be visualized. This technique will help reduce the
risk of accidentally touching or perforating an unanes-
thetized part of the TM. The pick is slowly advanced
into the middle ear cavity, and the stapes and long
process of the incus are then touched to assess their
movement. The myringotomy window may be closed
with a paper patch.
POSTOPERATIVE MANAGEMENT
Dry ear precautions should be in place until the myrin-
gotomy has healed. The patient should be seen at
follow-up in 3 weeks to ensure closure of the
myringotomy.
30˚
30˚
70˚
70˚
B
70˚
30˚
A
Figure 107-10. The visual fi eld of 30- and 70-degree endoscopes.
(Reprinted with permission from Kakehata S, Futai K, Kuroda R, et al:
Offi ce-based endoscopic procedure for diagnosis in conductive hearing loss
cases using OtoScan laser-assisted myringotomy. Laryngoscope 114:1285-
1289, 2004.)
PEARLS
• In any offi ce procedure, communicating with
the patient to maximize comfort is the key to
success.
• Anxiety surrounding offi ce procedures can be
reduced through installation of a video monitoring
system so that the patient can watch the procedure
in progress.
• Any solution introduced into either the ear canal or
the middle ear should fi rst be warmed to body
temperature to avoid inducing vertigo.
• When a mass in the EAC is suspected to be
infl ammatory in nature and topical therapy
is instituted, close monitoring for resolution
of the mass is critical, with biopsy of persistent
lesions.

Chapter 107
Offi ce-Based Procedures in Otology 1091
12. Noel SB, Scallan P, Meadors MC, et al: Treatment of Pseudomonas
aeruginosa auricular perichondritis with oral ciprofl oxacin. J Der-
matol Surg Oncol 15:633-637, 1989.
13. Margulis A, Bauer BS, Alizadeh K: Ear reconstruction after auric-
ular chondritis secondary to ear piercing. Plast Reconstr Surg
111:891-897, discussion 898, 2003.
14. Kaweski S, Baldwin RC, Wong RK, et al: Diffusion versus ionto-
phoresis in the transport of gentamicin in the burned rabbit ear
model. Plast Reconstr Surg 92:1342-1349, discussion 1350-1351,
1993.
15. Doyle KJ, Bauch C, Battista R, et al: Intratympanic steroid treat-
ment: A review. Otol Neurotol 25:1034-1039, 2004.
16. Silverstein H, Rowan PT, Olds MJ, et al: Inner ear perfusion and
the role of round window patency. Am J Otol 18:586-589, 1997.
17. Jackson LE, Silverstein H: Chemical perfusion of the inner ear.
Otolaryngol Clin North Am 35:639-653, 2002.
18. Blakley BW: Clinical forum: A review of intratympanic therapy.
Am J Otol 18:520-526, discussion 527-531, 1997.
19. Horii A, Saika T, Uno A, et al: Factors relating to the vertigo
control and hearing changes following intratympanic gentamicin
for intractable Meniere’s disease. Otol Neurotol 27:896-900,
2006.
20. Wu IC, Minor LB: Long-term hearing outcome in patients receiv-
ing intratympanic gentamicin for Meniere’s disease. Laryngo-
scope 113:815-820, 2003.
21. Blakley BW: Update on intratympanic gentamicin for Meniere’s
disease. Laryngoscope 110:236-240, 2000.
22. Pender DJ: Gentamicin tympanoclysis: Effects on the labyrinthine
sensory cells. Laryngoscope 113:343-348, 2003.
23. Trune DR, Kempton JB, Gross ND: Mineralocorticoid receptor
mediates glucocorticoid treatment effects in the autoimmune
mouse ear. Hear Res 212:22-32, 2006.
24. Parnes LS, Sun AH, Freeman DJ: Corticosteroid pharmacokinet-
ics in the inner ear fl uids: An animal study followed by clinical
application. Laryngoscope 109:1-17, 1999.
25. Chandrasekhar SS: Intratympanic dexamethasone for sudden
sensorineural hearing loss: Clinical and laboratory evaluation.
Otol Neurotol 22:18-23, 2001.
26. Kakehata S, Sasaki A, Oji K, et al: Comparison of intratympanic
and intravenous dexamethasone treatment on sudden sensori-
neural hearing loss with diabetes. Otol Neurotol 27:604-608,
2006.
27. Ferraro JA, Durrant JD: Electrocochleography in the evaluation
of patients with Meniere’s disease/endolymphatic hydrops. J Am
Acad Audiol 17:45-68, 2006.
28. Timmer FC, Zhou G, Guinan JJ, et al: Vestibular evoked myogenic
potential (VEMP) in patients with Meniere’s disease with drop
attacks. Laryngoscope 116:776-779, 2006.
29. Kakehata S, Futai K, Kuroda R, et al: Offi ce-based endoscopic
procedure for diagnosis in conductive hearing loss cases using
OtoScan laser-assisted myringotomy. Laryngoscope 114:1285-
1289, 2004.
PITFALLS
• Patients with deep retraction pockets, TM
perforations, or a mastoid bowl are particularly
susceptible to transient facial paralysis from local
anesthetics.
• If the temporal artery is punctured with an outer ear
block, pressure should be maintained for 20 to 30
minutes to avoid the formation of a hematoma.
• Biopsy of pulsatile, highly vascular lesions should
not be performed in the offi ce.
• Although relatively easy to perform, intratympanic
injection of gentamicin is associated with signifi cant
potential morbidity; therefore, nonablative options
should be exhausted and the patient must be fully
informed of the risks.
References
1. Krouse JH, Mirante JP, Christmas DA: Offi ce-Based Surgery in
Otolaryngology. Philadelphia, WB Saunders, 1999, p 273.
2. Siegel GJ, Chandra RK: Laser offi ce ventilation of ears with inser-
tion of tubes. Otolaryngol Head Neck Surg 127:60-66, 2002.
3. Hoffman RA, Li CL: Tetracaine topical anesthesia for myringot-
omy. Laryngoscope 111:1636-1638, 2001.
4. Smith WK, Sandooram D, Prinsley PR: Intratympanic gentamicin
treatment in Meniere’s disease: Patients’ experiences and out-
comes. J Laryngol Otol 120:730-735, 2006.
5. Hafner HM, Rocken M, Breuninger H: Epinephrine-supple-
mented local anesthetics for ear and nose surgery: Clinical use
without complications in more than 10,000 surgical procedures.
J Dtsch Dermatol Ges 3:195-199, 2005.
6. Gessler EM, Hart AK, Dunlevy TM, et al: Optimal concentration
of epinephrine for vasoconstriction in ear surgery. Laryngoscope
111:1687-1690, 2001.
7. Watson D: Torn earlobe repair. Otolaryngol Clin North Am
35:187-205, vii-viii, 2002.
8. Ghanem T, Rasamny JK, Park SS: Rethinking auricular trauma.
Laryngoscope 115:1251-1255, 2005.
9. Schuller DE, Dankle SD, Strauss RH: A technique to treat wres-
tlers’ auricular hematoma without interrupting training or com-
petition. Arch Otolaryngol Head Neck Surg 115:202-206, 1989.
10. Bassiouny A: Perichondritis of the auricle. Laryngoscope 91:422-
431, 1981.
11. Llera JL, Levy RC: Treatment of cutaneous abscess: A double-
blind clinical study. Ann Emerg Med 14:15-19, 1985.

Chapter 108
Foreign Bodies of the External
Auditory Canal
Barry E. Hirsch
A foreign body of the external auditory canal can pose
a real challenge to otolaryngologists. Foreign bodies are
more commonly seen in the pediatric population but
they do occur in adults. Insects, vegetable matter, and
inorganic material are the objects seen most frequently.
Removal of the material is important not only for reliev-
ing acute symptoms of pain, pressure, and hearing loss
but also to avoid potential sequelae of infection, canal
stenosis, and further hearing loss.
PATIENT SELECTION
The acute event resulting from entrapment of a foreign
body in the ear canal will bring most patients to the
attention of a physician. Such patients also include
adults, who become immediately aware that an object
that they were using to clean or manipulate the ear
becomes dislodged and is left in the external auditory
canal. The most common inorganic object creating this
problem is the end of a cotton-tipped applicator. After
ear cleaning, people may realize that the cotton tip is
no longer attached to the end of the applicator. Simi-
larly, other materials, such as facial tissue and paper,
can be rolled in an elongated fashion and used to probe
the ear. Institutionalized adults and children may also
use these materials for ear cleaning or packing. In this
population, if drainage, infection, or odor has not
developed, such material may be found only on routine
physical examination.
Along with using instrumentation to clean their
ears, adults also place objects in the ear canal for protec-
tion, including devices to minimize water exposure
because of recurrent otitis externa or perforation of the
tympanic membrane. Material used for hearing protec-
tion can become lodged or break off and remain in the
external canal. Examples of such products include sili-
cone putty used for sound or water protection and
Silastic occlusive plugs or foam inserts for sound protec-
tion. Again, patients become acutely aware of broken
off material remaining in the ear canal.
The list of objects that children can put in their ears
is endless. Unless a witness observes a child placing a
foreign body in the canal, its presence may not be dis-
covered until routine physical examination detects the
object or problems arise because of its presence. Objects
that occlude the ear canal could produce hearing loss.
This is a common chief complaint in an aware child or
adult. Infl ammation caused by the foreign object may
result in infection and drainage. Localized aural dis-
charge, cellulitis of the concha and external meatus, or
serosanguineous otorrhea would prompt further evalu-
ation. Certain materials pose more of a challenge to
extract from the canal. Once water enters the external
canal, vegetable materials such as beans and peas can
swell and cause obstruction, pain, and maceration.
Other materials that have been found in the ear canal
include small toys, beads, erasers, crayons, pits from
fruit, disc batteries, nuts, and stones. Disc batteries
should be removed as soon as possible to avoid the liq-
uefaction necrosis that results when moisture and secre-
tions permit fl ow of electrons.1 Irrigation of the ear
canal should be avoided to minimize the risk of generat-
ing an electric current. Similarly, unsuccessful attempts
at removal of the battery that result in trauma and
bleeding in the ear canal would also allow fl ow of
current and therefore further tissue destruction.
Insects occasionally fi nd their way into the ear
canals of children and adults alike. These are usually
fl ying insects, but crawling insects may also enter the
canal, especially when people are asleep. Patients
become acutely aware of their presence because of the
insect’s noise and the induced pain. Management in
1093

1094
Section 12
Otology
this situation becomes more urgent than that needed
for inanimate objects.
PREOPERATIVE PLANNING
In most situations, removal of a foreign body is an elec-
tive event. This permits planning in terms of the appro-
priate instrumentation, lighting, the need for and type
of anesthesia, and the method of extraction. Adult or
pediatric patients with otorrhea, hearing loss, and
obstruction or occlusion of the ear canal who fail to
respond to topical and systemic therapy may have
pathology of the middle ear and mastoid or foreign
bodies causing their symptoms and fi ndings. If medical
therapy fails to reduce the infl ammation that limits
visualization of the medial canal and tympanic mem-
brane, computed tomography is appropriate to assess
the status of the external canal, middle ear, and
mastoid.
Management of insects in the ear canal requires
additional material. A live insect can be diffi cult and
painful to extract. Various solutions, including ether,
isopropyl alcohol, and mineral oil, are effective in
drowning and killing the insect before fl ushing or
extraction. Topical tetracaine (Pontocaine) or lido-
caine (Xylocaine) solution can also be used to sub-
merge and paralyze the insect in the ear canal.2 This is
readily available in all emergency room settings.
Foreign bodies can be categorized not only by their
chemical composition but also by their shape and con-
sistency. Understanding the physical properties of a
foreign body facilitates the choice of method for
removal. Soft and wet objects similar to cerumen can
be suctioned or fl ushed from the canal. Firm or hard
foreign bodies require specifi c instruments for extrac-
tion. Round objects may get wedged at the bony isthmus
or the cartilaginous-bony junction. Small foreign bodies
may shift to the medial canal and get caught in the
anteroinferior sulcus between the tympanic membrane
and the bony canal.
Another classifi cation system categorizes the foreign
bodies into two groups: objects with smooth surfaces
and not easily grasped (nongraspable) and objects with
irregularly shaped surfaces and easily grasped. In a
study of pediatric patients treated in emergency depart-
ments for foreign bodies in the ear canal, it was noted
that beads were the most common objects. When the
foreign bodies were group by nongraspable and grasp-
able, the success rate for removal of a graspable object
was 64% with a 14% complication rate. In contrast, suc-
cessful removal of a nongraspable object occurred in
only 45% of cases with a 70% complication rate. It was
concluded that skilled emergency department person-
nel could handle pediatric patients with graspable
foreign bodies in the ear canal with low complication
rates. Nongraspable foreign objects should be referred
to an otolaryngologist early in the course of their
management.3
A variety of instruments need to be available before
extracting a foreign body in the ear canal. Otologic
examination of the external auditory meatus (or
mastoid cavity) identifi es the presence of the foreign
object. Its shape and consistency are noted. Small
objects can readily be removed with a hand-held oto-
scope and operating head.
In a series of 698 pediatric patients with foreign
bodies in the external auditory canal, Schulze and col-
leagues proposed indications for referral for otomicros-
copy-guided removal. These indications were categorized
by the type of foreign body (spherical or sharp-edged
shape, disc batteries, and vegetable matter), location of
the foreign body (adjacent to the tympanic membrane),
time in the ear (>24 hours), patient description (<4
years of age with diffi culty visualizing the foreign object,
agitation, or both), and a history of previous attempts
at removal.4
Objects with an unusual shape that are wedged in
the ear canal often require maximal lighting and more
dexterous manipulation. An operating microscope pro-
vides the necessary light and the means for bimanual
removal. Some of the instruments that should be avail-
able include various-sized ear specula; a water irrigation
kit; small, medium, and large suction devices; ring and
wire loop curettes; right-angled hooks; and picks. If
necessary, the use of progressively larger specula facili-
tates exposure and dilatation of the canal. Injectable
local anesthetics such as lidocaine with epinephrine
should be available when manipulation and extraction
are potentially painful.
It is important to determine whether the foreign
object has penetrated the tympanic membrane or
middle ear. Patients with acute hearing loss and dizzi-
ness should be suspected of injury transmitted to the
inner ear. If available, an audiogram should be obtained
to determine the nature and degree of the hearing loss.
Exploration of the ear under intravenous sedation or
general anesthesia should be considered for patients in
whom damage to the ossicular chain or inner ear is
suspected. General anesthesia will probably be neces-
sary for most children and anxious, uncooperative
adults.
SURGICAL TECHNIQUES
Removal of Insects
Flying or crawling insects that enter the external canal
typically need to be removed urgently. Live insects can
cause pain and ongoing irritation because of their
movement and potential trauma to the tympanic mem-
brane. The noise and disturbing sensation created by
live insects drive patients to seek urgent medical atten-
tion. The ear canal and tympanic membrane are
inspected to identify the species of insect and the
trauma it may have caused. The presence of loose
appendages such as wings or legs should be noted. The
patient is placed supine with the involved ear facing up.
The ear canal is fi lled with one of the previously men-
tioned solutions (ether, isopropyl alcohol, mineral oil,
tetracaine, or lidocaine). This may incur a fl urry of
activity as the insect drowns. Should the patient have
severe pain, the skin of the external canal can be infi l-

Chapter 108
Foreign Bodies of the External Auditory Canal 1095
trated with local anesthetic. The insect is extracted from
the canal with suction, which also removes the excess
solution. Ideally, the insect is removed with the suction
tip as well. It may be necessary to remove the insect with
alligator forceps. Once the insect is removed, the canal
is carefully inspected for residual body parts, which are
carefully removed with forceps or a fi ne, cotton-tipped
applicator. The integrity of the ear canal skin and tym-
panic membrane is verifi ed.
Removal of Vegetable Material
Foreign bodies such as peas, beans, nuts, and corn have
the potential to swell as a result of oil secretions from
the canal, water from swimming or showering, or
attempts at fl ushing the ear. If the object is relatively
dry and intact, extraction with suctioning may simply
remove the material. It may be necessary to place a
small, right-angled hook behind the object to manipu-
late it into the lateral canal. Flushing these objects out
is not recommended to avoid swelling, maceration, and
disruption of the integrity of the object. However, if the
object is soft, crumbling, and friable and cannot be
extracted with suction, irrigation may be necessary.
Warm tap water typically suffi ces for such irrigation.
Mixing hydrogen peroxide with an equal volume of
water mechanically facilitates aural fl ushing. An irrigat-
ing system such as that shown in Figure 108-1 is most
effective. Other systems would include a large-gauge
angiocatheter attached to a syringe. Large metal ear
syringes are also available for this purpose. Care is taken
to avoid directing excessive pressure at the tympanic
membrane.
Management of foreign bodies in children is par-
ticularly challenging. One must assess the nature of the
foreign body and the anticipated degree of technical
diffi culty that will be necessary to extract it. If the object
is relatively intact and can be removed with suction
or just a few passes of a right-angled instrument,
effort should be made to extract it without general
anesthesia, which may require that the child be
restrained by the parents or an assistant or be wrapped
in a sheet like a papoose. If the foreign body is impacted,
it is usually necessary to take the child to the operating
room and, under masked general anesthesia, extract
the object.
Objects that are wedged in the ear canal medial to
the cartilaginous-bony junction pose a signifi cant chal-
lenge. By using sequentially larger ear specula, attempts
are made to dilate the lateral external auditory meatus
to facilitate extraction. A large-gauge suction placed on
the object may remove it from the canal. Care must be
taken to avoid further impaction and medialization
with this technique (Fig. 108-2). If this method is unsuc-
cessful, a right-angled hook (Fig. 108-3) is passed
beyond the object and withdrawn laterally. Passing the
instrument in the anterior inferior canal should be
avoided because of the thin skin and sensitivity of the
canal. The superior and posterior quadrants have
thicker skin that is more readily compressed. If manipu-
lation of the ear is uncomfortable, a local anesthetic
can be injected into the canal skin. A small volume
should be used to minimize further edema from the
injected solution. After adequate anesthesia has been
achieved, extraction can proceed in a more relaxed
setting.
A novel idea for removing an object that is diffi cult
to extract is to attach an anchor to the foreign body.
Isaacson described applying a quick-setting epoxy adhe-
sive to a foreign body that is spherical in shape with a
smooth surface and impacted medially in the canal.
This was done in a two-step procedure by applying the
fi rst layer of glue to the foreign body in the clinic 1 to
2 days in advance. After 10 minutes, a second layer was
applied to a small metal anchor (a no. 8 machine screw
with a fashioned concave surface), which was then
attached to the foreign object. The child was taken to
Figure 108-1. A DeVilbiss irrigating system (syringe and bottle
DV177) connected to a positive pressure air source is used to fl ush
soft material from the external auditory canal.
Figure 108-2. A large-gauge suction is usually successful in remov-
ing most objects from the external auditory canal. Care must be taken
to not push the foreign body more medially.

1096
Section 12
Otology
the operating room 2 days later, at which time a fi rm
grasp on the anchor permitted extraction through the
ear canal.5
On rare occasions, larger objects cannot be
extracted despite the techniques previously described.
This usually occurs when the foreign body has been
wedged medially beyond the cartilaginous meatus.
Children and rarely adults may require general anesthe-
sia for more complete foreign body removal. The ear
canal and postauricular area are prepared and draped
in sterile manner. The largest ear speculum that fi ts
into the external auditory meatus is placed into the
meatus. If a hook cannot be advanced beyond the
object, it may be necessary to open the incisura with an
incision made at the 12-o’clock position down to the
bony canal. This permits further dilatation of the exter-
nal canal and facilitates advancement of an instrument
(Fig. 108-4).
Perforation of the tympanic membrane with possi-
ble disruption of the ossicular chain may occur as a
result of a foreign object placed in the ear. The pene-
trating object, such as a cotton-tipped applicator, pencil,
bobby pin, stick, or knitting needle, is usually long and
narrow. It is often removed or readily extracted at the
time of injury.
Intravenous sedation or general anesthesia is pre-
ferred for patients in whom perforation of the tympanic
membrane is suspected. After removal of the foreign
body, the tympanic membrane is carefully inspected.
Small central perforations or lacerations are repaired
with Gelfoam placed in the middle ear medial to the
tympanic membrane defect or with a paper patch
applied to the lateral surface of the tympanic mem-
brane (see Chapter 113). Patients with signifi cant con-
ductive or sensorineural hearing loss should undergo
exploratory tympanotomy for evaluation of the integrity
of the ossicular chain and the round and oval windows.
Details regarding repair of the ossicular chain and oval
window can be found in Chapters 114 and 117,
respectively.
Occasionally, it may be necessary to undertake a
postauricular approach. In such cases, a postauricular
incision is made down to the posterior wall of the bony
external auditory canal, similar to the postauricular
approach for exostoses of the external auditory canal
(see Chapter 109). A lateral conchal fl ap is incised
through the ear canal. A postauricular incision is made
and connected with the conchal fl ap, and tracheostomy
tape and a self-retaining retractor are positioned to
Figure 108-3. A right-angled hook is passed beyond the object,
which is then extracted laterally.
Figure 108-4. An incision is made in the incisura (12-o’clock posi-
tion) of the external auditory meatus to widen the meatus and permit
an instrument to be passed medial to the foreign body.
Figure 108-5. The ear has been refl ected anteriorly to expose the
lodged foreign object medially.

Chapter 108
Foreign Bodies of the External Auditory Canal 1097
refl ect the auricle anteriorly for postauricular exposure
of the meatus lateral to the foreign body (Fig. 108-5).
A right-angled hook can be passed anterosuperiorly
beyond the object and extracted laterally. If excessive
trauma and laceration of canal skin are anticipated with
extraction of the object, a fl ap of canal skin pedicled
inferiorly is raised. The foreign body is removed, and
the canal skin and auricle are returned to their original
positions. The ear canal should be stented to immobi-
lize any skin fl aps and avoid stenosis. Care is taken to
avoid trapping of epithelium by unrolling folded edges
and reapproximating skin fl aps to the best fi t. Methods
for packing the ear canal include the use of Gelfoam,
a Merocel ear pack, or a rosebud packing made of silk
strips and cotton balls (see Chapter 113).
POSTOPERATIVE MANAGEMENT
Patients having foreign bodies extracted from the ear
canal who incur minimal trauma and have no associ-
ated infl ammation require no further treatment. Should
maceration or cellulitis preexist or laceration and
infl ammation occur during extraction, topical eardrops
are advised. Ototopical antibiotics, usually containing
steroids, are instilled twice daily, depending on the
severity of infl ammation. The patient is instructed to
avoid further water contamination by keeping the ear
free of swimming pool or shower water. Vaseline applied
to a cotton ball is usually effective in keeping the ear
canal dry.
If signifi cant cellulitis has developed or the patient
is diabetic, the use of systemic antibiotics may be neces-
sary. Staphylococcus aureus and Pseudomonas aeruginosa
are the organisms most likely to be involved. Oral cip-
rofl oxacin should be effective in treating external canal
cellulitis.
Patients who require external canal stenting or
packing are also treated with topical antibiotic drops.
The Gelfoam, canal pack, or rosebud pack serves as a
wick for delivering the topical drops. Wicks meant to
be placed for a short time, such as a Pope otowick, are
generally removed after 3 days unless there is severe
infl ammation or laceration of the canal skin. The wick
then remains for 1 week. The patient removes the wick
and continues applying topical drops. Patients in whom
a Merocel ear pack or rosebud pack is placed are seen
in approximately 1 week. The packing is removed and
the canal inspected. Topical drops are continued for a
few more days. The patient continues to keep the ear
free of water exposure for a few weeks, at which time
examination of the ear canal is performed to confi rm
complete healing.
References
1. Capo JM, Lucente FE: Alkaline battery foreign bodies of the ear
and nose. Arch Otolaryngol Head Neck Surg 112:562-563, 1986.
2. Bressler K, Shelton C: Ear foreign-body removal: A review of 98
consecutive cases. Laryngoscope 103:367-370, 1993.
3. DiMuzio J Jr, Deschler DG: Emergency department management
of foreign bodies of the external ear canal in children. Otol Neu-
rotol 23:473-475, 2002.
4. Schulze SL, Kerschner J, Beste D: Pediatric external auditory canal
foreign bodies: A review of 698 cases. Otolaryngol Head Neck Surg
127:73-78, 2002.
5. Isaacson G: Two-stage removal of an impacted foreign body with
an epoxied anchor. Ann Otol Rhinol Laryngol 112:777-779,
2003.
PEARLS
• Aural irrigation to remove foreign bodies (other
than insects) in the external auditory canal should
be avoided because the object is rarely fl ushed out
and skin maceration often results.
• Live insects can be drowned with alcohol, mineral
oil, or topical anesthetics (Pontocaine, Xylocaine).
• A large nasal suction (9F) device may make
suffi cient contact with the object to remove it from
the canal.
• Passing a right-angled hook parallel to the object
and then beyond it allows optimal placement of
instruments for extraction.
• Injection of a local anesthetic followed by canal
dilatation with progressively larger specula may
facilitate removal of the foreign body.
PITFALLS
• Instrumental removal of a live insect without
drowning it can intensify the pain and stimulation
experienced by the patient.
• Instrumentation directed medially along the
posterior ear canal may contact and traumatize the
tympanic membrane.
• Aggressive manipulation may result in more medial
impaction and possible injury to the tympanic
membrane and ossicular chain.
• Failure to recognize and properly reapproximate
lacerated canal skin may lead to trapped epithelium
and the development of canal cholesteatoma.
• Repeated unsuccessful attempts at foreign body
removal will result in canal trauma, further
obstruction, and an uncooperative patient.

Chapter 109
External Canal Osteomas and Exostoses
Barry E. Hirsch
The contour of the cartilaginous and bony external
auditory canal is S shaped. Direct inspection of the
tympanic membrane may be obscured by a prominent
anterior canal wall forming an acute angle with the
tympanic membrane. Normal aural hygiene is facili-
tated by epithelial migration from the tympanic mem-
brane to the external auditory meatus. Irregular bony
overgrowth may impede this process and predispose
the ear to epithelial entrapment and recurrent otitis
externa.
Exostoses of the external auditory canal represent
hyperplasia of the periosteum and underlying bone.
When exostoses are present, they are typically seen in
men, and a history of cold-water swimming can fre-
quently be obtained. Examination of 307 surfers at a
California surfi ng competition revealed a 73.5% preva-
lence of exostoses.1 In a recent study of 202 avid surfers
on the east coast of the United States, the prevalence and
degree of canal obstruction were assessed. Their surfi ng
habits (location/water temperature) and duration of
practicing the sport were recorded, along with the
patency of their ear canals. Most of the surfers (84%)
were categorized as warm-water surfers (>60º F). There
was a 38% overall prevalence of external canal exostoses,
with 69% graded as mild and 31% as moderate to severe.
Those participating in the sport for a longer time and
exposed to cold water had a much greater incidence of
exostoses. In addition, surfers with moderate to severe
obstruction were signifi cantly more willing to surf in cold
water than those who had mild exostoses.2
Occasionally, patients will deny any water exposure
yet will still manifest these bony overgrowths. Exostoses
are usually multiple in number and have a smooth
contour. They are broad-based, convex, epithelium-
covered nodules located in the medial aspect of the
external auditory canal (Fig. 109-1). These lesions are
typically found bilaterally. Dense lamellae of bone are
evident histologically.3
Osteomas are benign bony lesions of unknown
origin that have an outer cortex of bone with inner
cancellous trabeculations. Osteomas are singular,
pedunculated, unilateral lesions generally located at
the tympanomastoid or tympanosquamous suture lines.
Osteomas may vary in size from a few millimeters to
larger than 2 cm (Fig. 109-2).4
Exostoses are relatively common and are seen in
6.36 of every 1000 patients treated by ear, nose, and
throat departments, in contrast to the rare incidence of
osteomas. Osteomas are to be considered true bone
tumors, and exostoses are believed to be reactions to
irritation from cold-water immersion or chronic otitis
externa. However, in a histopathologic review by Fenton
and coworkers, many of the features of trabeculated
bone, such as lamellar deposition of bone and fi brovas-
cular channels, were seen in specimens clinically diag-
nosed as osteoma and exostoses.5
Osteomas and exostoses are usually asymptomatic.
They are often identifi ed by an internist or family prac-
titioner, who subsequently requests otologic consul-
tation. Signifi cant canal obstruction or chronic skin
changes initiate recurrent ear symptoms. Osteomas or
exostoses that signifi cantly encroach on the canal lumen
may impede migration of desquamated epithelium,
thereby predisposing the patient to recurrent episodes
of otitis externa. Both lesions, when extensive, may
produce hearing loss by either occlusion of the canal
or impacted epithelial debris inhibiting vibration of the
tympanic membrane. Exostoses usually encroach on
the external auditory canal in an anteroposterior direc-
tion. Superiorly based lesions located near the pars fl ac-
cida may grow inferiorly and restrict movement of the
malleus. It is estimated that approximately 80% of the
ear canal needs to be obstructed to cause symptoms of
recurrent otitis externa and conductive hearing loss.
Occlusion less than this degree rarely necessitates oper-
ative intervention.6
1099

1100
Section 12
Otology
Recurrent otitis externa occurs when epithelial
debris is trapped between the tympanic membrane and
osteoma and becomes macerated and colonized with
bacteria. Débridement of the external auditory canal
and the use of topical otic preparations are necessary
for each acute infectious episode. These recurrent
infections frequently result in chronic dermatitis and
further canal obstruction.
PATIENT SELECTION
Surgical intervention is not usually necessary when
exostoses or osteomas are identifi ed. Periodic cleaning
of cerumen and epithelial debris medial to the lesions
may be necessary. The prophylactic use of eardrops is
recommended for patients who are continually exposed
to water. Swimming without ear protection may have to
be curtailed if it is the predisposing event for recurrent
infections. Surgical intervention is indicated when
patients experience chronic or recurrent otitis externa
or when reaccumulation of epithelial debris and ceru-
men impaction cause conductive hearing loss.
Surgical treatment of external auditory canal exos-
toses may be associated with complications and the
need for revision surgery. Initial symptoms include
hearing loss, recurrent otitis externa, and cerumen
impaction. In a series of 136 patients undergoing
surgery for exostoses, it was found that 21% had no
symptoms and were advised to have surgery based on
their clinical examination. The author of this review
emphasized that surgery should be reserved for pa-
tients with ear symptoms because, even in experienced
hands, surgery is associated with a potential risk for
complications.7
Patients with a perforated tympanic membrane or
conductive hearing loss from ossicular chain problems,
in addition to exostoses, may have to undergo a staged
procedure. The obstruction of the external auditory
canal and recurrent infection may need to be addressed
initially, and after subsequent healing, the second pro-
cedure may be performed.
PREOPERATIVE PLANNING
Patients undergoing surgery for recurrent otitis externa
should have optimal preoperative medical care, includ-
ing cleaning of the external auditory canal and mini-
mizing infl ammation with topical otic preparations. An
audiogram is necessary to determine the presence and
degree of conductive or sensorineural hearing loss. If
symptoms are present bilaterally, surgical intervention
is directed at the more involved ear. In the event of
signifi cant bilateral disease, the procedure should be
staged to ensure unilateral healing and avoid the handi-
cap of bilateral ear packing.
On occasion, lesions may totally obstruct the ear
canal and thus prohibit examination of the tympanic
membrane. In this situation, computed tomography is
necessary to defi ne the origin and extent of the bony
lesions, particularly with osteomas located laterally in
the canal (Fig. 109-3). Coronal and axial bone window
A
B
Figure 109-1. A, View of the
right
external
auditory
canal
revealing multiple broad-based
exostoses located medially near
the tympanic membrane. B, Left
external auditory canal with mul-
tiple obstructing exostoses obscur-
ing the tympanic membrane.
Figure 109-2. Excised osteoma of the external auditory canal with
its narrow pedicle located on the right side of the bony tumor.

Chapter 109
External Canal Osteomas and Exostoses 1101
time of surgery, it may be necessary to harvest a split-
thickness skin graft (Thiersch graft). Along with
informed consent for the canal procedure, patients
should be told of the possible need for a skin graft.
SURGICAL TECHNIQUE
The pedunculated attachment of osteomas to suture
lines in the external auditory canal can be removed
through a transmeatal approach. A four-quadrant block
consisting of an anesthetic solution of 2% lidocaine
(Xylocaine) with 1:100,000 epinephrine is injected into
the external auditory meatus. After adequate local anes-
thesia has been achieved, a middle ear curette or right-
angled hook is passed beyond the osteoma. If exposure
is inadequate for visualization or instrumentation, the
soft tissue at the incisura at the 12-o’clock position may
be compressed or incised to permit passage of an instru-
ment beyond the osteoma (Fig. 109-5). An overlying
skin fl ap can be incised and preserved if the osteoma is
attached by a broad base (Fig. 109-6A and B). If the
osteoma is on a narrow pedicle, the osteoma can usually
be fractured with a curette and removed. Occasionally,
it may be necessary to use a small osteotome or drill to
weaken the base. Once the osteoma is removed, the
bony base is further drilled to the level of the bony
external canal. A small strip of silk or a piece of Gelfoam
impregnated with antibiotic ointment is used as a topical
dressing (see Fig. 109-6C).
Exostoses are generally multiple and broad based.
Greater surgical exposure routinely requires a postau-
ricular approach, usually performed with the patient
under general anesthesia. The postauricular hair is
shaved and the ear is prepared and draped in the usual
sterile fashion. A solution of 2% lidocaine with 1:100,000
epinephrine is injected in a four-quadrant block into
the external auditory meatus and the postauricular
crease. The exposure and approach are similar to those
used for postauricular tympanoplasty techniques (see
Chapter 113). Endaural incisions in the 12- and 6-
o’clock positions are made in the lateral meatus and
Figure 109-3. Right external auditory canal with a posteriorly
based osteoma (O) obstructing complete examination of the medial
canal and tympanic membrane. P, posterior.
A
B
Figure 109-4. Axial (A) and
coronal (B) bone-windowed com-
puted tomography images demon-
strating a pedunculated attachment
to the lateral posterior canal wall
(arrows). The remaining external
auditory canal and middle and
inner ear are normal.
images assist the surgeon in identifying the lesion and
the appropriate approach (Fig. 109-4). The radiologic
characteristics differentiating osteomas from exostoses
have been described. An osteoma arises from the tym-
panosquamous or tympanomastoid suture line, and its
density is slightly lower than that of normal bone, which
suggests that it consists of mainly cancellous bone.8 An
isolated osteoma, as demonstrated, may easily be
removed with the patient under local anesthesia.
Obstructive exostoses that require drilling are per-
formed with the patient under general anesthesia.
Removal of multiple large irregular exostoses may result
in trauma to the canal epithelium. If the canal skin is
not suitable for replacement or is inadequate at the

1102
Section 12
Otology
connected vertically to create a conchal fl ap. The medial
extent of the skin fl ap extends approximately 3 to 4 mm
beyond the hair-bearing canal (Fig. 109-7). A postau-
ricular incision is made, the conchal fl ap is elevated
from the lateral posterior canal wall, and the two inci-
sions are connected. A tracheostomy tape is used to
refl ect the conchal fl ap with the external auditory
meatus anteriorly (Fig. 109-8). A self-retaining retractor
holds the auricle and posterior conchal skin fl ap ante-
riorly to provide direct exposure to the more medial
canal.
Skin fl aps based medially are carefully dissected
from the anterior and posterior canal walls. A medium-
sized cutting burr is used to remove the bony exostoses
while leaving a thin shell of bone attached to the canal
skin. Dissection is performed in a lateral-to-medial
direction toward the tympanic membrane. The suction
tip is used to protect the canal skin fl ap from the shaft
and burr of the drill. If space permits, thin Silastic sheet-
ing or a section of foil from a suture pack is positioned
to provide additional protection to the canal wall skin
(Fig. 109-9). As the bony overgrowth is removed, direct
examination of the tympanic membrane becomes fea-
sible. Once exposure is gained, the fl ap is returned to
its newly contoured canal and the opposite wall is
treated in a similar fashion. A thick, crescent-shaped
section of bone often remains at the medial aspect of
the dissection. Care is taken to further elevate the medi-
ally based skin fl ap distal to this shelf of bone as it
approaches the tympanic membrane. The remainder of
C
B
A
Figure 109-5. An incision made in the incisura widens the aperture
to the external auditory meatus. A curette is positioned medial to the
osteoma in preparation for removal. The tympanic membrane is
ghosted in.
Figure 109-6. A, Broad-based osteoma (O) of the left ear located
on the anterior external auditory canal wall. A, anterior; S, superior.
B, A skin fl ap (F) based medially was created and returned to cover
the exposed bone. C, A strip of silk (S) is positioned on the anterior
canal wall to secure the skin fl ap.

Chapter 109
External Canal Osteomas and Exostoses 1103
the bone is removed to create a smoothly contoured
canal. More aggressive bone removal can be under-
taken anteriorly. Because such bone removal encroaches
on the posterior aspect of the temporomandibular
joint, care must be taken to avoid trauma to the perios-
teum surrounding the joint capsule. Medium and small
diamond burrs are used to further smooth the walls of
the bony canal. Care is taken to avoid drilling into the
tympanic membrane, the bony lateral process of the
malleus, and the tympanic annulus. Aggressive drilling
of the posterior canal wall can lead to injury to the
mastoid air cells and should be avoided.
It may be diffi cult to leave the anterior or posterior
skin pedicled medially. Should additional bone work be
necessary in an area obstructed by the skin fl ap, rather
than tearing it with the drill burr or shaft, the skin can
be removed in a large rectangular section to provide
the exposure needed. The skin can subsequently be
replaced when the bony canalplasty is completed.
Once drilling is completed, the skin is repositioned,
although it is not necessary to completely cover all areas
of denuded bone. If the skin fl aps have been preserved,
they are adequate for epithelial coverage. However,
large areas of exposed bone should be grafted to facili-
tate more rapid and uncomplicated healing. Freehand
split-thickness skin sections (Thiersch grafts) measur-
ing approximately 1.0 by 1.5 cm are harvested with a
no. 10 blade from the postauricular skin overlying the
mastoid (Fig. 109-10). The feathered edges of the skin
graft are trimmed sharply. The grafts are placed over
areas of raw bone while avoiding overlapping the edges
of the surrounding skin. It is necessary to secure the
skin fl aps (and grafts) by packing the medial and lateral
canal. If the original canal skin was pedicled and pre-
served, the canal can be packed with a single Merocel
stent (Fig. 109-11). When the original skin or graft is
replaced in sections, fi rm reapproximation and immo-
bilization are achieved with rosebud packing, which
consists of multiple strips of silk placed in the ear canal.
Cotton or Merocel balls impregnated with antibiotic
ointment are placed in the depth of the packing and
brought out to the level of the midcanal. The ear is
returned to its anatomic position, the conchal fl ap is
Figure 109-7. Through the external auditory meatus, a conchal
fl ap is incised and back-elevated. Note the narrowed bony canal
medially.
Figure 109-8. A postauricular incision has been made and a tra-
cheostomy tape is placed to evert the conchal fl ap within the canal
(arrow). A self-retaining retractor (not shown) provides the necessary
exposure.
Figure 109-9. Beginning laterally, the posterior canal wall skin is
elevated and protected with a sheet of suture pack foil or Silastic. The
suction tip is used to retract the skin and maintain a clean surgical
fi eld. The bony exostosis is drilled to contour the canal.

1104
Section 12
Otology
Figure 109-10. Excessive loss of canal skin should be replaced. A
freehand split-thickness Thiersch graft is harvested from the postau-
ricular skin overlying the mastoid.
Figure 109-11. A Merocel ear pack secures the canal wall skin
fl aps.
Figure 109-12. Double-rosebud packing is used to secure skin that
was replaced in sections.
repositioned, and a second rosebud packing is placed
(Fig. 109-12) (see Chapter 113). The postauricular
wound is closed with 5-0 fast-absorbing suture and Steri-
Strips. A cotton ball is placed in the external meatus,
and a Glasscock or sterile mastoid dressing is applied.
The routine method for removing these bony
lesions is to use a high-speed otologic drill. Some sur-
geons advocate the use of a mallet and a thin 1- to 3-mm
chisel or osteotome. It has been proposed that the bony
mass can be serially shaved with these instruments.
This technique may also minimize noise and vibration
trauma from the drill.6,9
Rather than completely removing all the exostoses
from both the anterior and posterior canal walls, an
alternative strategy is to address only exostoses of the
anterior wall of the external auditory canal. This still
places the temporomandibular joint at risk but mini-
mizes complications related to disruption of the ossicu-
lar chain and injury to the chorda tympani and facial
nerve.10
POSTOPERATIVE MANAGEMENT
Systemic antibiotics are not administered unless there
is concern for ongoing low-grade chronic infection and
cellulitis. Patients undergoing a postauricular approach
have the mastoid dressing removed the following
morning. Oral narcotic analgesics are prescribed when
necessary. The cotton ball in the conchal meatus may
need to be changed frequently in the fi rst few postop-
erative days, depending on the amount of serosan-
guineous drainage. Antibiotic-steroid eardrops are
administered twice daily. After 7 to 10 days, patients are
seen for follow-up. Sutures and the lateral rosebud
packing are removed from those who have undergone
postauricular canalplasty. Antibiotic-steroid eardrops
are continued twice a day, and the patient is seen the
following week, at which time the medial rosebud
packing is removed.

Chapter 109
External Canal Osteomas and Exostoses 1105
The donor site for the split-thickness skin graft is
treated with topical antibiotic ointment twice a day.
Patients are asked to wash their hair in a sink to avoid
potential water contamination or maceration.
Patients who have isolated lesions (osteomas)
removed by the endomeatal approach are seen 10 days
postoperatively, at which time the silk sleeve or Gelfoam
packing is removed. Flat de-epithelialized areas are
allowed to heal further by secondary intention. Topical
eardrops are continued for a few weeks until complete
healing has occurred.
Despite attempts to meticulously approximate epi-
thelial fl aps within the external auditory canal, there
may be areas of exposed bone medially and de-epithe-
lialized subcutaneous tissue laterally. Careful cleaning
and débridement of the ear are performed when the
second packing is removed. Areas of hypertrophied
granulation tissue are cauterized with silver nitrate, and
antibiotic-steroid drops are continued. Frequent, dili-
gent, and meticulous care should be given to canal
hygiene to avoid postoperative stenosis. Should en-
croachment of the canal lumen develop, a stent consist-
ing of multiple Pope otowicks or strips of Merocel
microporous sponge is placed in the canal and remains
for an additional week. The canal is reevaluated and
appropriate local care is given. Patients demonstrating
irregular epithelization and midcanal stenosis or medial
canal soft tissue blunting may need to be returned to
the operating room. In this situation, hypertrophied
soft tissue is débrided and a single fi rm stent consisting
of long rosebud silk packing is inserted. Topical ear-
drops are administered, and the stent is removed in 10
days. Silver nitrate is usually effective for control of
excessive granulation tissue. 5-Fluorouracil cream may
also be applied if silver nitrate alone is unsuccessful.
The fi rst few postoperative weeks are critical to the
healing process. It may be necessary to see patients
weekly to monitor and control wound healing. Despite
the appearance of appropriate epithelialization, patients
are restricted from water exposure for at least 2 months.
A cotton ball with Vaseline is used while showering.
Swimming is prohibited until complete healing has
taken place.
COMPLICATIONS
Patients undergoing removal of exostoses usually have
a history of chronic otitis externa. They are prone to
wound-healing problems and thus require close obser-
vation. Exuberant granulation tissue may heal with a
midcanal stenosis or medial blunting at the level of the
tympanic membrane.
The structures surrounding the external auditory
canal are subject to potential injury during the opera-
tive procedure. Aggressive drilling of bony lesions on
the posterior wall may result in injury to the mastoid air
cell system. Migration of epithelium into these cells
would potentially lead to fi stulization or cholesteatoma
formation. Similarly, drilling the anterior canal wall
may lead to entry into the capsule of the temporoman-
dibular joint. Small areas of bony dehiscence are toler-
ated if the periosteum is not violated. However, large
areas of bone removal lead to prolapse of the soft tissues
of the temporomandibular joint into the external audi-
tory canal. This not only retards wound healing in the
immediate postoperative period but may also pro-
duce subsequent aural hygiene problems. Clicking or
other auditory sounds may occur with mandibular
movement.
Structures potentially at risk when drilling the canal
medially are the chorda tympani nerve, the tympanic
membrane, and the malleus. The chorda tympani may
be drilled in the area just medial to the posterior
annulus. The tympanic membrane may be torn by the
drill or other instruments used during dissection of the
canal skin. The lateral process of the malleus may also
be hit by the drill and result in conductive or sensori-
neural hearing loss.
Inadequate bone removal may give rise to persis-
tent symptoms. This typically occurs at the interface of
the tympanic membrane and the anteromedial canal
wall. An acutely angled anterior sulcus may continue to
trap epithelial debris and promote the persistence of
symptoms.
When the skin of both the anterior and posterior
canals is violated, postoperative canal stenosis can occur.
Caution is needed during the procedure, and height-
ened awareness is necessary during the immediate post-
operative period to avoid and recognize this problem.
Débridement of exuberant granulation tissue and
repacking of the canal should be undertaken once this
process is recognized.
Patients experiencing persistent infl ammation or
chronic otitis externa should be suspected of having
allergic dermatitis secondary to topical otic drops. Prep-
arations containing aminoglycosides should be discon-
tinued in favor of other topical agents. Steroid cream
preparations may be necessary if an allergic reaction
develops.
Facial nerve injury is a devastating complication
after surgery for exostoses. The facial nerve is relatively
close to the posteroinferior annulus. A facial nerve with
an aberrant course that is lateral and more anterior to
its normal position may potentially be damaged and
result in inadvertent facial paresis. The surgeon should
anticipate this problem while drilling the bony postero-
inferior canal. Facial nerve monitoring during the pro-
cedure should help minimize the likelihood of this
untoward event.
PEARLS
• Surgical intervention is not usually necessary when
exostoses and osteomas are asymptomatic.
• Computed tomography scans of the temporal bone
should be obtained when the ear canal and
tympanic membrane cannot be examined.
• A single osteoma located laterally in the ear canal
and attached by a narrow pedicle can be removed
with a curette under local anesthesia.

1106
Section 12
Otology
References
1. Wong BJ, Cervantes W, Doyle KJ, et al: Prevalence of external
auditory canal exostoses in surfers. Arch Otolaryngol Head Neck
Surg 125:969-972, 1999.
2. Kroon DF, Lawson ML, Derkay CS, et al: Surfer’s ear: External
auditory exostoses are more prevalent in cold water surfers. Oto-
laryngol Head Neck Surg 126:499-504, 2002.
3. Nager GT, Hyams VJ: Pathology of the Ear and Temporal Bone.
Baltimore, Williams & Wilkins, 1993, p 1341.
4. Senturia BH, Marcus MD, Lucente FE: Diseases of the External
Ear: An Otologic-Dermatologic Manual, 2nd ed. New York, Grune
& Stratton. 1980, p 204.
5. Fenton JE, Turner J, Fagan PA: A histopathologic review of tem-
poral bone exostoses and osteomata. Laryngoscope 106:624-628,
1996.
6. Whitaker SR, Cordier A, Kosjakov S, Charbonneau R: Treatment
of external auditory canal exostoses. Laryngoscope 108:195-199,
1998.
7. Vasama JP: Surgery for external auditory canal exostoses: A report
of 182 operations. ORL J Otorhinolaryngol Relat Spec 65:189-
192, 2003.
8. Hsiao SH, Liu TC: Osteoma of the external ear canal. Otol Neu-
rotol 24:960, 2003.
9. Hetzler D, Longridge NS: Exocytosis of the external auditory
canal. Otol Neurotol 24:523, author reply 523, 2003.
10. Longridge NS: Exostosis of the external auditory canal: A techni-
cal note. Otol Neurotol 23:260-261, 2002.
• Caution is needed when drilling the posterior and
inferior bony canal walls because of the proximity of
the facial nerve.
• Facial nerve monitoring is advisable during surgical
removal of exostoses.
PITFALLS
• Surgical intervention in patients with limited
symptoms may result in greater problems
postoperatively than before surgery.
• Aggressive drilling of the posterior inferior external
auditory canal may result in injury to the facial
nerve.
• Contact between the surgical drill and the ossicular
chain may cause sensorineural hearing loss.
• External canal stenosis can occur when excessive skin
is sacrifi ced or traumatized.
• Failure to recognize and intervene when signifi cant
narrowing of the canal is seen in the early
postoperative period will result in infl ammatory
stenosis and conductive hearing loss.

Chapter 110
Keratosis Obturans and Canal
Cholesteatoma
Yael Raz
Keratosis obturans and canal cholesteatoma were ini-
tially attributed to the same pathologic process, and the
two terms were used interchangeably.1 Both conditions
are associated with disruption in the normal outward
migration of external auditory canal epithelium, a
process critical for extrusion of desquamated skin.2 Pie-
pergerdes and colleagues are credited with defi ning
these two entities as unique processes requiring distinct
management algorithms.3 Nevertheless, partial overlap
between these two conditions has led to continued
debate in the recent literature over appropriate
nomenclature.4,5
In keratosis obturans, the defect in lateral epithelial
migration is circumferential and results in the forma-
tion of a laminar keratin plug that can frequently be
removed intact as a cast of the external canal (Figs.
110-1 and 110-2). The keratin plug may extend medially
to the tympanic membrane. Conductive hearing loss is
common secondary to an occlusive effect. The condi-
tion is typically bilateral and may be accompanied by
otalgia. Widening of the external auditory canal can
occur as a result of circumferential bony resorption,
presumably secondary to constant pressure induced by
the keratin plug. The canal epithelium typically remains
intact and can become thickened or infl amed. Early
reports suggested an association with bronchiectasis
and sinusitis, particularly in children.6,7 Otorrhea is
rare.
Canal cholesteatoma, in contrast, appears most
commonly as a keratin “pearl,” usually situated on the
fl oor of the external canal (Fig. 110-3). Canal cholestea-
tomas are generally unilateral and characterized by
ulceration of the canal skin and focal bony erosion (Fig.
110-4). Hearing is not usually affected because the canal
is not completely occluded and the middle ear is spared.
After removal of the cholesteatomatous matrix, the
bony canal is exposed and often eroded. Epithelium
surrounding the bony defect will generally show sharply
demarcated edges, although bleeding and granulation
tissue are occasionally present. Whereas the appearance
of keratosis obturans is diffi cult to confuse with other
entities, the same cannot be said for canal cholestea-
toma. Suspicion of carcinoma must be entertained and
biopsy of the margins of the crater in the canal should
be performed routinely. Bone exposure within the
external auditory canal and the presence of granulation
tissue may also be confused with acute necrotizing otitis
(malignant external otitis). However, the latter condi-
tion is accompanied by signifi cant pain and a greatly
elevated erythrocyte sedimentation rate and is almost
universally seen in diabetic patients. Furthermore, iden-
tifi cation of Pseudomonas in culture would be expected
in acute necrotizing disease, whereas normal canal fl ora
is generally cultured from canal cholesteatoma.
The chief distinction between keratosis obturans
and canal cholesteatoma lies in circumferential widen-
ing of the bony canal in the former as opposed to focal
bony erosion in the latter and visual determination of
whether the canal epithelium remains intact or whether
bone has become exposed. As yet, there is no clear
understanding of the cause of the abnormalities in epi-
thelial migration that characterize keratosis obturans
and canal cholesteatoma. However, recent work on
factors involved in the regulation of cell-cell adhesion
and epithelial proliferation has begun to shed light on
the molecular processes that may be involved.8,9
Although this discussion is limited to idiopathic canal
cholesteatomas, entrapment of squamous epithelium
may occur in the setting of congenital or acquired canal
atresia or after temporal bone trauma or surgery.
1107

1108
Section 12
Otology
B
A
Keratin
casts
A
B
Figure 110-1. A and B, Views of the external auditory meatus showing complete obstruction with a keratin plug.
Figure 110-2. A and B, Keratin plugs after removal from the ear
canals.
Canal
cholesteatoma
Figure 110-3. Otoscopic view of a canal cholesteatoma forming in
the inferior canal wall.

Chapter 110
Keratosis Obturans and Canal Cholesteatoma 1109
PATIENT SELECTION
Canalplasty has been described on rare occasions for
intractable keratosis obturans10; however, conservative
management suffi ces in most cases. Emollients and
lubricants will aid in the removal of keratotic plugs, but
no drugs have been found to successfully eliminate the
problem. Steroid and exfoliative agents have been tried
with limited success, but simple lubrication of the
keratin plug before removal remains the most effective
treatment. Over time, each patient will determine the
correct interval necessary for serial canal cleaning to
prevent hearing loss, obstruction, and secondary
infection.
Small canal cholesteatomas can also be managed
conservatively, provided that the patient is free of otalgia
and the entire extent of the affected area can be visual-
ized and accessed for cleaning. Even extensive canal
erosion with bone exposure can be managed conserva-
tively in elderly patients for long periods without resort-
ing to surgical intervention. Signifi cant otalgia is rare
and permits consideration of surgery in patients with
the following criteria: (1) those living at a great distance
or who have diffi culty traveling regularly for cleaning
of the ear; (2) individuals with repeated bleeding from
ulcerated skin margins and those in whom repeated
secondary canal infections develop; (3) patients who
electively wish a more permanent alternative to repeated
cleaning of the ear canal; and (4) large lesions with
involvement of the middle ear, facial canal, or mastoid
air cells. Reassurance, as well as biopsy in cases of canal
erosion, will suffi ce in the great majority of cases to
satisfy patients that ongoing conservative treatment is
the method of choice.
PREOPERATIVE EVALUATION
In large canal cholesteatomas, preoperative imaging
with temporal bone computed tomography can be
helpful in determining the extent of involvement of
mastoid air cells or the facial nerve canal and assist
in deciding whether facial nerve monitoring will be
necessary.
SURGICAL APPROACHES
Local anesthesia is the method of choice in patients
who elect to undergo surgery. The purpose of surgery
is to remove infected or unhealthy skin, eliminate devi-
talized bone, smooth the contours of the bony canal,
and fi nally, reline the denuded area of the canal.
A postauricular approach provides the best expo-
sure of the affected canal. The postauricular incision is
combined with a short conchal fl ap extending to the
level of the defect in the canal. The auricle is then
refl ected anteriorly in the standard tympanoplasty-
mastoidectomy fashion (Fig. 110-5). After exposing the
area of canal erosion, unhealthy tissue is débrided from
the epithelial border, and the skin adjacent to the
defect is refl ected medially for optimal exposure.
Appropriately sized cutting and diamond burrs are
then used to removed devitalized bone and smooth the
contours of the canal defect. Bone is removed until
healthy bleeding osseous tissue is encountered (Fig.
110-6). Lesions of the posteroinferior canal may extend
into the mastoid air cells. When the cells are of suffi -
cient size, they should be obliterated with fat or fascia
before applying the skin graft. At this point, the area of
denuded bone is determined. If minimal coverage is
required, the bony canal can be lined with temporalis
fascia. Extensive areas of bone exposure can be resur-
faced with a split-thickness skin graft approximately
Figure 110-4. Otoscopic view of exposed and eroded bone after
removal of a cholesteatoma matrix.
Figure 110-5. Postauricular approach for resculpting and grafting
of a canal wall defect.

1110
Section 12
Otology
Figure 110-6. Use of cutting and diamond burrs to remove seques-
trum and expose fresh, viable bone.
Split-thickness
skin graft
Packing
Figure 110-7. Packing is placed in the canal to stabilize the split-
thickness skin graft.
0.012-inch thick. The authors prefer the upper inner
aspect of the arm as a donor site, but other convenient
areas may be used as well. It is seldom necessary to take
more than about 1 square inch of skin for repair of
canal defects of this type. Previously elevated skin fl aps
in the canal are replaced, and the conchal fl ap is
returned to its original position. After the skin graft
is placed over the defect, a strip of silk or rayon mesh
is laid over the graft to protect and prevent movement
of it. Finally, continuous packing soaked in antibiotic
ointment is gently layered into the canal (Fig. 110-7).
The postauricular incision is then closed and dressed
in the usual manner.
Larger canal cholesteatomas involving signifi cant
exposure of the mastoid air cells may require recon-
struction of the canal wall (i.e., with hydroxyapatite) or
a modifi ed radical mastoidectomy. Facial nerve moni-
toring should be considered for these lesions because
the cholesteatoma can erode into the facial canal.
POSTOPERATIVE MANAGEMENT
The packing is removed in 10 to 14 days, and simple
débridement of the skin edges is carried out until
healing is complete. It is rare for canal cholesteatomas
to recur, but desquamation from the skin graft site may
continue for a period of several months. During this
time, the application of mineral oil in small amounts
will prevent desquamated epithelium from accumulat-
ing. Healing is usually complete within 6 to 10 weeks.
COMPLICATIONS
Complications include facial nerve injury, recurrence
of cholesteatoma, injury to the tympanic membrane or
malleus, and persistent exposed bone. The facial nerve
is particularly at risk when drilling in the medial,
postero-inferior aspect of the canal and caution is
required in this region. If the mastoid air cell system is
entered, skin may grow through the defect resulting in
a fi stula or recurrent cholesteatoma. This can be pre-
vented by using fat, fascia or cartilage to obliterate the
exposed cells. If the pathology is located medially, the
tympanic membrane or malleus may be injured during
drilling of the bony canal. The surgeon must be mindful
of the deep aspect of the rotating burr and downsize
appropriately to avoid iatrogenic hearing loss or a per-
foration. Assuring the removal of all devitalized bone,
as well as careful positioning of an adequately sized
graft, can help prevent incomplete epithelialization.
PEARLS
• It is important to remove all devitalized bone
because failure to do so will lead to loss of the
overlying skin graft. Bleeding must be seen from
all newly freshened bone surfaces to ensure an
adequate nutritional bed for the graft.
• Histologic examination of skin edges must be
performed to rule out malignancy.
• Desquamation from the skin graft may continue
for several months postoperatively and requires
frequent débridement until healing is complete.
PITFALLS
• Extensive drilling of the posteroinferior canal wall
may expose the vertical portion of the facial nerve,
and thus caution must be exercised in this region.
• Otorrhea or recurrence of canal cholesteatoma may
result if the mastoid air cells are not obliterated with
fat or fascia before skin grafting.

Chapter 110
Keratosis Obturans and Canal Cholesteatoma 1111
4. Persaud RA, Hajioff D, Thevasagayam MS, et al: Keratosis obturans
and external ear canal cholesteatoma: How and why we should
distinguish between these conditions. Clin Otolaryngol 29:577-
581, 2004.
5. Kuczkowski J, Mikaszewski B, Narozny W: Immunohistochemical
and histopathological features of keratosis obturans and choles-
teatoma of the external auditory canal. Atypical keratosis
obturans. J Laryngol Otol 118:249-250, author reply 250-251,
2004.
6. Black JIM, Clayton RG: Wax keratosis in children’s ears. BMJ
2:673-675, 1958.
7. Morrison AW: Keratosis obturans. J Laryngol Otol 70:317-321,
1956.
8. Naim R, Riedel F, Bran G, Hormann K: Expression of beta-
catenin in external auditory canal cholesteatoma (EACC). Biofac-
tors 19:189-195, 2003.
9. Adamczyk M, Sudhoff H, Jahnke K: Immunohistochemical inves-
tigations on external auditory canal cholesteatomas. Otol Neu-
rotol 24:705-708, 2003.
10. Paparella MM, Goycoolea MV: Canalplasty for chronic intractable
external otitis and keratosis obturans. Otolaryngol Head Neck
Surg 89:440-443, 1981.
• Preoperative consent for harvesting of a split-
thickness skin graft should be obtained lest the
operating room staff be caught unprepared in the
event that an extensive area of bony exposure is
encountered.
References
1. Paparella M, Shumrick D: Otolaryngology, vol 2. Philadelphia,
WB Saunders, 1973, p 37.
2. Naiberg J, Berger G, Hawke M: The pathologic features of kera-
tosis obturans and cholesteatoma of the external auditory canal.
Arch Otolaryngol 110:690-693, 1984.
3. Piepergerdes MC, Kramer BM, Behnke EE: Keratosis obturans
and external auditory canal cholesteatoma. Laryngoscope 90:383-
391, 1980.

Chapter 111
Congenital and Acquired Atresia of the
External Auditory Canal
Elizabeth H. Toh and Barry E. Hirsch
Atresia of the external auditory canal may be congenital
or acquired (Figs. 111-1 and 111-2). Congenital atresia
is much more common, with a reported incidence of 1
in 10,000 to 20,000 births, and is often associated with
deformities of the auricle and middle ear. Congenital
atresia results from developmental abnormalities in the
fi rst and second branchial arches during the fi rst tri-
mester of fetal life. Although the vast majority of these
defects are sporadic, 10% occur as part of a syndromic
abnormality. Acquired atresia of the external auditory
canal is unusual and may occur secondary to trauma,
chronic infl ammation, radiation therapy, or iatrogenic
injury after surgery. Other terminology used to describe
this acquired condition includes postinfl ammatory
acquired atresia of the external auditory canal, postin-
fl ammatory medial canal fi brosis, and chronic stenos-
ing external otitis.1-3
Congenital atresia occurs more commonly in males
than females and is most often unilateral, with the right
ear affected more often than the left. The atresia is
more frequently bony than membranous. Associated
anomalies of the inner ear occur in less than 20% of
patients, so most atresia cases are amenable to surgical
correction. The pinna is rarely completely normal or
totally absent (anotia). At minimum, there are usually
cartilaginous or soft tissue remnants from faulty embry-
ologic development. Mild deformity or microtia is
common (Fig. 111-3). In general, the appearance of the
external ear correlates well with development of the
middle ear.4
Because of anomalous development of the fi rst and
second branchial arches, anatomic anomalies of the
facial nerve are generally present. Middle ear abnor-
malities such as fi xation of the malleus, fusion of the
malleus-incus complex, fi xation of the stapes footplate,
anomalous position of the chorda tympani, and a per-
sistent stapedial artery have also been described. Inner
ear dysplasia may involve the cochlea, the vestibule, the
semicircular canals, and the internal auditory canal.
Congenital atresia of the external auditory canal
has been seen in association with hydrocephalus, pos-
terior cranial hypoplasia, hemifacial microsomia, cleft
palate, and genitourinary anomalies. Syndromes in
which congenital atresia has been described include
Treacher Collins, Goldenhar, trisomy 22, Klippel-Feil,
cleidocranial dysplasia, Fanconi, Crouzon’s, DiGeorge,
and thalidomide toxicity.
PATIENT SELECTION
Congenital Atresia
The goals of reconstruction of atresia of the ear include
provision of functional hearing and creation of a dry
and patent external auditory canal. In 1992, Jahrsdoer-
fer and associates devised a grading scale using preop-
erative computed tomography (CT) scans to evaluate a
child’s candidacy for correction of atresia.5 These
authors assigned one point for each of eight factors
detected on CT imaging (Table 111-1), plus two points
if the stapes was normal. A perfect score of 10 yields an
excellent prognosis for hearing improvement to within
a 15 to 20 dB speech reception threshold, and the con-
verse would hold true for a diminishing number of
normal structures identifi ed on CT imaging. The prog-
nosis for hearing improvement is expressed as a per-
centage relative to the assigned CT score. A zero added
to each score indicates the percent chance of achieving
closure within 15 to 20 dB. Surgery is not usually recom-
mended when the score is 5 or less. When applying the
results of this evaluation, surgeons must also consider
their own experience, as well as other potential prob-
1113

1114
Section 12
Otology
Table 111-1
GRADING SYSTEM TO DETERMINE
CANDIDACY FOR SURGICAL
CORRECTION OF CONGENITAL
AURAL ATRESIA
Parameter
Points
Stapes present
2
Oval window open
1
Middle ear space
1
Facial nerve
1
Malleus-incus complex
1
Mastoid pneumatized
1
Incus-stapes connection
1
Round window
1
Appearance of the external ear
1
Total available points
10
Absence of external
auditory canal
Atretic canal
A
B
Figure 111-1. Lateral (A) and coronal (B) views of the temporal
bone in a patient with congenital aural atresia.
Atretic
ear canal
Lateral ossicular mass
in middle ear
Absence of
external
auditory canal
Middle ear
B
A
Figure 111-2. Computed tomography scans of aural atresia in the
axial (A) and coronal (B) planes.
Figure 111-3. Typical appearance of microtia associated with aural
atresia.

Chapter 111
Congenital and Acquired Atresia of the External Auditory Canal 1115
lems with the child’s general health and otologic
status.
In the great majority of patients with congenital
atresia, reconstruction of the pinna must also be
planned and timed appropriately along with the atresia
repair. Surgical reconstruction of the pinna should be
completed or at least initiated before atresia repair to
take advantage of the uncompromised blood supply in
the temporal area. Reconstruction of the pinna is a
complex and often multistage procedure that may be
performed with rib cartilage or synthetic material. The
use of rib and rib cartilage for reconstruction of the
pinna results in an external ear that is more resistant to
trauma, infection, and extrusion. However, synthetic
Silastic or porous polyethylene material may result in a
cosmetically superior pinna. Regardless of the method
of reconstruction, the otologist must ensure that
the atresia surgery does not jeopardize the circulation
of the auricular reconstruction.
Correction of the atresia at or after the age of 5
years allows optimal development of the mastoid
process, adequate time for initiating repair of the micro-
tia, and maturity of the child to participate in postop-
erative care. When corrective surgery for unilateral
atresia is delayed past early childhood, cosmetic correc-
tion of the microtia can and should be accomplished
in the usual manner. A 4- to 6-month interval between
microtia and atresia repair is generally recommended.
The presence of cholesteatoma in the atretic canal may
be identifi ed by bone erosion on preoperative CT and
may dictate the need for earlier surgery.
Acquired Atresia
The most common form of acquired canal atresia
involves soft tissue obliteration of the external auditory
canal only. The intervening segment between the patent
canal laterally and the tympanic membrane usually con-
sists of fi brous tissue. Chronic otitis externa and chronic
suppurative otitis media are the most common inciting
causes. Acquired atresia may develop after severe trauma
to the temporal bone with fracture of the anterior or
posterior canal walls. Infl ammation, such as severe seb-
orrheic dermatitis and other dermatologic conditions,
may result in severe scarring and obliteration of the soft
tissues of the external canal over time. Acquired atresia
may also occur after burns and may represent the mid-
canal or medial canal type of fi brosis after tympanomas-
toid surgery. The fi nal common pathway in the
development of an atretic canal is an exuberant fi bro-
proliferative infl ammatory response, which typically
occurs over the course of years.
In the early infl ammatory phase of the disease, con-
servative medical management with aggressive aural
toilet and the application of steroid-containing ototopi-
cal antibiotics plays some role in controlling any under-
lying infection and minimizing the development of
granulation tissue. Once mature fi brosis of the canal
has developed, the ear is generally dry and hearing loss
remains the only functional concern. Because the goal
of surgery is hearing improvement when the acquired
atresia is unilateral, as is usually the case, the option for
amplifi cation should be offered to the patient. Derma-
tologic disease processes must be made quiescent before
surgical repair is attempted. Active seborrheic dermati-
tis with scaling and exudation does not provide a good
environment for surgical repair and reconstruction.
When thickened skin obstructs the external meatus and
there is no evidence of further active disease after the
formation of pachyderma, reconstruction is a plausible
approach for hearing improvement. Aural rehabilita-
tion with a bone-anchored hearing aid (BAHA) may be
offered to select patients who do not elect to undergo
atresia repair and are unable to use a conventional
hearing aid in the affected ear because of auditory feed-
back or fi tting problems. Candidates for BAHA use
must have an underlying cochlear reserve of at least
40 dB in the better-hearing ear.
PREOPERATIVE EVALUATION
Congenital Atresia
When fi rst evaluating a child with congenital atresia
of the external auditory canal, the physician must
obtain a comprehensive history and perform a physical
examination to determine whether the atresia is an
isolated fi nding or part of a syndromic or hereditary
problem. When the latter appears to be the case, genetic
counseling may be indicated for future family
planning.
The educational needs and philosophy of atresia
repair must be considered. Because the great majority
of affected children have unilateral atresia, it must be
determined whether hearing is normal in the opposite
ear. Sensorineural hearing loss is occasionally identifi ed
in the nonatretic ear and must be investigated further.
When hearing in the nonatretic ear is normal, the
option for conservative management should be weighed
against the risks associated with surgery. Speech and
language acquisition can be ensured in these children,
even if surgery is delayed until they reach their teens or
if a decision is made to not proceed with surgery. The
presence of atresia at birth will almost certainly ensure
that audiometric testing is performed early in child-
hood. In very young children, auditory brain stem
response (ABR) measurements can easily approximate
auditory threshold levels. By the age of 4 or 5 years,
behavioral audiometric testing can be performed.
Reliable responses typically demonstrate maximal
conductive hearing loss with normal cochlear reserve.
It used to be recommended that surgery for unilateral
atresia be postponed until a child had reached the
age of self determination. With advances in CT, intra-
operative facial nerve monitoring, and greater surgical
experience, these guidelines are less rigid. Elective
surgery is now performed on unilateral atresia when the
parents have been carefully counseled and strongly
desire it.
A child with bilateral atresia will undergo the same
audiologic evaluation as previously described but
requires careful and expert evaluation with bone con-

1116
Section 12
Otology
duction ABR testing. In these cases, the “near-fi eld”
effect of the generator site ensures a larger wave I on
the ipsilateral side. Immediate amplifi cation with bone
conduction hearing aids is well accepted by small chil-
dren and will ensure normal speech acquisition and
language development until the child is old enough for
surgery. It is generally agreed that children with bilat-
eral atresia should undergo surgical repair in one ear
by the age of 5 years for the reasons indicated earlier.
The higher-graded ear is generally operated on fi rst.
Evaluation of a patient with aural atresia must
include high-resolution, thin-cut CT in both the axial
and coronal planes. Newer spiral CT machines offer the
ability to generate high-quality reconstructed coronal
images from the axial sequences obtained, thus reduc-
ing the overall dose of radiation delivered. These views
permit thorough evaluation of the degree of mastoid
and middle ear pneumatization, inner ear morphology,
facial nerve anatomy, and ossicular abnormalities. Inner
ear dysplasia, such as Mondini’s malformation or a
large vestibular aqueduct, increases the risk for senso-
rineural hearing impairment with surgery, which must
be discussed with the parents. Review of the CT scans
will also inform the surgeon of the presence of canal
cholesteatoma, as suggested by an expansile soft tissue
density with adjacent bony erosion.
A word is necessary regarding BAHAs in the treat-
ment of congenital atresia. They are not generally
advised if repair of microtia is being considered because
the surgery necessary for their implantation jeopardizes
the blood supply necessary for cosmetic reconstruction
of the pinna. In addition, children with favorable results
on the CT rating scale have an excellent chance of
achieving reasonable hearing. Even when children
attain speech reception thresholds that are slightly
worse than normal, they will benefi t from using in-canal
hearing aids once atresia surgery has been performed.
BAHAs remain a rehabilitative recommendation for
children in whom imaging suggests a poor prognosis
for successful hearing improvement and in those who
elect to not undergo surgery. The recommended lower
age limit for implantation of a BAHA device is currently
5 years.
Acquired Atresia
Because the primary goal of surgery for acquired atresia
is improvement in hearing, preoperative audiologic
testing will help confi rm the nature and extent of loss
in the affected ear. The fi brous plug alone will often
result in a 25- to 30-dB conductive hearing loss. The
patient should be counseled that any additional under-
lying sensorineural hearing loss would probably neces-
sitate the use of a conventional hearing aid in the
operated ear once the ear canal has healed.
Preoperative high-resolution CT imaging of the
temporal bone in the axial and coronal planes is helpful
in differentiating bony from soft tissue atresia, detect-
ing the presence of underlying cholesteatoma, and
assessing the status of the middle ear and ossicular
chain.
SURGICAL APPROACHES
Congenital Atresia
Surgical correction should not be attempted before the
pinna has been reconstructed and correctly placed in
relation to the anticipated location of the external
canal. This can easily be determined by palpating the
mastoid tip and temporomandibular joint to ensure
that the proposed meatus will be properly located just
behind the condyle of the mandible. The preoperative
CT scan is reviewed again and particular attention is
paid to the intratemporal course of the facial nerve,
level of the tegmen, and depth of the middle ear cavity
from the surface of the skull. Intraoperative facial nerve
monitoring should be performed in all cases.
A standard postauricular C-shaped incision is made
after infi ltration with a solution of 1% lidocaine with
1:100,000 epinephrine. Every attempt is made to pre-
serve all circulation to the auricle originating from the
anterior, inferior, and superior aspects (Fig. 111-4),
which may occasionally require placement of the inci-
sion further posteriorly than would ordinarily be done
for routine mastoid surgery. The mastoid periosteum is
incised and the soft tissue overlying the mastoid is then
elevated anteriorly until the glenoid fossa is well identi-
fi ed (Fig. 111-5). A temporalis fascial graft is harvested,
thinned, and dried for construction of a new tympanic
membrane. The external canal should be created just
behind the glenoid fossa and just inferior to the tem-
poral line (Fig. 111-6). The temporal bone sometimes
has a small depression or cribriform area that marks the
location of the undeveloped external auditory canal. In
other cases, a soft tissue plug is present that may be
followed directly into the atretic plate or the tympanic
membrane. When external canal landmarks are absent,
drilling should begin as close to the glenoid fossa and
Figure 111-4. Postauricular incision with an attempt to maintain
the blood supply to the pinna.

Chapter 111
Congenital and Acquired Atresia of the External Auditory Canal 1117
tions. The most common anomaly is an anterior and
sometimes lateral deviation of the vertical trunk of the
facial nerve (Fig. 111-7), which occurs in up to 25% of
cases. The nerve may traverse the promontory, round
window, or hypotympanum, or it may be inferior to the
tympanic annulus, if present. In this situation the
surgeon will generally encounter the atretic plate
without exposing the nerve, assuming that drilling has
been confi ned to the area described earlier. When soft
tissue is initially encountered, drilling should be per-
formed with diamond burrs from that point on. The
atretic plate is then thinned until the bone is paper-thin
and can be gently lifted away from the fi brous remnants
of the tympanic membrane and ossicular chain with
angled picks or elevators (Fig. 111-8). Trauma to the
ossicular chain must be avoided during drilling to
prevent sensorineural hearing loss. The most common
ossicular abnormality is a fused malleus-incus complex.
Incudostapedial connection by means of a fi brous
Temporal line
Glenoid fossa
Figure 111-5. Identifi cation of the glenoid fossa (right ear).
Glenoid fossa
Temporal line
Figure 111-6. Creation of an external meatus just inferior to the
tegmen and just posterior to the glenoid fossa (left ear).
middle fossa dural plate as possible. In doing so, bone
must be preserved between the glenoid fossa and what
is to become the anterior canal wall. By following the
middle fossa dural plate medially, the atretic plate will
generally be encountered at a depth of approximately
1.5 cm. Unlike routine mastoid surgery, drilling should
be confi ned to a relatively small circumference to avoid
the creation of a mastoid cavity. Mastoid air cells may
be encountered, but they should be minimally exposed
if the drilling is confi ned to the location of the atretic
canal. The diameter of the external auditory canal that
is being created should be only 1.5 times larger than
normal (about 1.3 cm in diameter).
Although intraoperative monitoring helps the
surgeon minimize trauma to the facial nerve, the
general location of this structure should be carefully
reviewed on the CT scan preoperatively. In the great
majority of cases, the horizontal portion and the second
genu of the facial nerve will be in relatively normal posi-
Normal course of the
facial nerve
Abnormal course
of the facial nerve
in aural atresia
A
B
Figure 111-7. A, Normal course of the facial nerve and the course usually seen in atresia. B, Coronal computed tomography scan showing
anterior displacement of the mastoid segment of the facial nerve.

1118
Section 12
Otology
strand or stapedial arch discontinuity is sometimes
found. Footplate fi xation occasionally occurs as well.
When necessary, ossiculoplasty is performed as it would
be during tympanoplasty with bony or cartilaginous
autografts or various PORPs (partial ossicular replace-
ment prostheses) and TORPs (total ossicular replace-
ment prostheses). Separation of the incudomalleal
complex is generally unnecessary because it is usually
mobile. Occasionally, the malleus neck is fi xed to the
atretic plate by means of a bony spur, in which case it
must be separated and mobilized. In rare cases, the
ossicular chain may be fi xed at more than one location,
and complete mobilization of the chain is necessary to
ensure optimal postoperative hearing results. The use
of an argon laser for lysis of soft tissue adhesions and
bony attachments during this portion of the procedure
will help minimize the risk of sensorineural hearing loss
from excessive manipulation of the ossicular chain.6
After ossiculoplasty, a 1.5-mm diamond burr is used
to create a bony annulus and sulcus on which to place
the fascial graft used for creating the new tympanic
membrane. Anteriorly, this minimizes blunting of the
anterior meatal angle. Thorough irrigation of the newly
created ear canal and middle ear space is critical at this
point to prevent postoperative bony refi xation of the
ossicular chain. If a PORP or TORP has been used for
ossiculoplasty, irrigation should be performed before
placement of the prosthesis. The fascial graft is then
centered over the ossicular mass to optimize hearing
results (Fig. 111-9). The fascia is extended for 1 to 2 mm
onto the newly developed bony annulus, and when pos-
sible, a small extension of the fascial graft may be placed
into the hypotympanum or protympanum to prevent
lateralization of the new tympanic membrane. Any air
cells uncovered in the process of drilling the new canal
are obliterated with connective tissue plugs to prevent
iatrogenic cholesteatoma resulting from ingrowth of
skin into the mastoid cavity.
A split-thickness skin graft 0.008- to 0.010-inch thick
and approximately 2 × 3 inches in dimension is har-
vested from one of several donor sites, including the
medial surface of the upper part of the arm, the supe-
rior lateral quadrant of the buttocks, or lower part of
the abdomen. A thinner graft is less likely to curl at the
edges and will reduce the rate of postoperative canal
stenosis. The circumference of the tympanic mem-
brane, the length of the canal, and the circumference
of the external meatus are measured with a length of
suture material. The skin graft is then cut to the appro-
priate size with these measurements (Fig. 111-10). The
external meatus must be created by excising conchal
skin and any underlying rib graft or prosthesis when
Figure 111-8. Curetting away the remnants of the bony atresia
plate overlying the lateral ossicular chain.
Figure 111-9. The fascial graft is placed over the ossicular mass
and placed into the bony annulus and canal.
Figure 111-10. Split-thickness skin graft trimmed to measured
dimensions and contoured along its medial border to allow place-
ment over the fascial graft.

Chapter 111
Congenital and Acquired Atresia of the External Auditory Canal 1119
they are present in this area. The meatal opening should
overlie the newly created canal and should admit the
surgeon’s thumb to compensate for postoperative con-
tracture (Fig. 111-11).
The previously measured skin graft is then placed
epithelial side down onto a Silastic sheeting template
that is 0.04 inch thick. Bacitracin ointment is spread
onto the Silastic sheeting to enhance adherence of the
skin graft. The Silastic template is cut to the same size as
the overlying skin. The Silastic is curled and placed in
the canal, where it then unfurls and holds the graft
against the canal wall. The medial edges of the skin graft
are extended 1 mm over the fascial graft (Fig. 111-12).
An additional disc of Silastic marginally smaller than
the diameter of the newly created canal may be placed
against the tympanic membrane to discourage blunting
of the new tympanic membrane (Fig. 111-13). The
lateral edges of the skin graft are sutured to the meatus
with 4-0 chromic suture (Fig. 111-14). Packing is then
A
B
Figure 111-11. A, Creation of the meatus in the pinna. B, Ensuring
adequate diameter of the meatus to make allowance for shrinkage.
Fascial graft
Split-thickness
skin graft
Figure 111-12. The split-thickness skin graft is placed with its
medial border overlapping the fascial graft by 1 mm.
Figure 111-13. A reinforced Silastic disc is placed over the fascial
graft after the split-thickness skin graft has been placed.
Figure 111-14. The lateral border of the split-thickness skin graft
is sutured to the external meatus.

1120
Section 12
Otology
placed in the canal and consists of a single large Merocel
wick, which once positioned in the newly created canal
is hydrated with an ototopical solution to hold the skin
graft in place. Alternatively, silk strips may be layered in
the canal and the canal packed with Merocel sponges
soaked with an ototopical solution (Fig. 111-15). The
postauricular incision is then closed in the usual fashion
with 4-0 Vicryl or Dexon, and a soft mastoid dressing is
applied.
Some surgeons used to prefer a mastoidectomy
technique wherein a “canal wall–down” type of cavity is
created to correct congenital atresia. Although this
technique may be successful in restoring hearing, it
introduces the added problem of a mastoid cavity. We
do not advocate this technique.
Acquired Atresia
Most of these patients will have soft tissue atresia as a
result of previous surgery or a chronic infl ammatory
process. The goals of surgery are to remove the fi brous
plug, expose the tympanic membrane, and re-epitheli-
alize the ear canal with normal healthy skin. Preopera-
tive CT scanning will confi rm the presence of any bony
atresia. If drilling will be necessary for bony atresia,
intraoperative facial nerve monitoring should be per-
formed. A postauricular approach is generally recom-
mended for wide surgical access. Repair via endaural
approaches has been uniformly unsuccessful.7
After infi ltrating the postauricular region and ear
canal with a solution of 1% lidocaine with 1:100,000
epinephrine, a circumferential canal incision is initially
made at the junction of the normal medial conchal skin
margin and the lateral aspect of the canal stenosis/
atresia. A standard postauricular incision is then made
down to the level of the temporalis fascia superiorly and
the mastoid periosteum inferiorly. The mastoid perios-
teum is incised in along the linea temporalis and then
down to the mastoid tip. Surgical dissection is contin-
ued under the periosteum anteriorly to the level of the
cartilaginous ear canal. Ear canal skin and soft tissue
are then gently elevated off the bony external auditory
canal (Fig. 111-16). This dissection proceeds medially
until the tympanic membrane is identifi ed (Fig. 111-
17). There is usually an identifi able plane between the
fi brous external canal plug and the fi brous layer of the
tympanic membrane. In cases of bony atresia, a combi-
nation of small cutting and diamond drill burrs is used
to carefully enlarge the bony canal. Care should be
exercised to not expose mastoid air cells posteriorly
when doing so. The goal of canalplasty should be to
provide a direct unobstructed view of the entire tym-
panic membrane through the external auditory meatus.
B
A
Figure 111-15. A, Silk strips are layered in the ear canal. B, Packing
is placed within the silk lining to maintain the skin graft in place.
Figure 111-16. Postauricular approach for acquired atresia.

Chapter 111
Congenital and Acquired Atresia of the External Auditory Canal 1121
POSTOPERATIVE MANAGEMENT
Self-absorbing suture material is used for both the
skin graft and the postauricular incision. The mastoid
dressing is removed 24 hours after surgery and the
ear is kept dry. The canal wick is continually hydrated
with antibiotic eardrops. Patients are seen 7 days post-
operatively to remove Steri-Strips from the postauricu-
lar incision and inspect the canal wick. After removal
of the canal wick at day 10 to 14, the patient is seen
every 2 weeks until the skin graft is completely healed.
Desquamation during this period is common, and
frequent cleaning of the ear canal may be necessary.
Small layers of granulation tissue may also develop in
the seams between the edges of the skin graft, but fre-
quent examination allows débridement and cauteriza-
tion of this tissue before it becomes bothersome or
obstructive. The use of steroid-containing ototopicals
may be of benefi t in this situation. The initial postopera-
tive audiogram is obtained 6 to 8 weeks after surgery,
when healing is mostly complete. Thereafter, the patient
is seen at 6- to 12-month intervals for routine cleaning
of the ear.
Hearing is generally improved immediately postop-
eratively but may deteriorate over time. The best hearing
results have been reported by Jahrsdoerfer and cowork-
ers, with 67% of patients attaining speech reception
thresholds of 30 dB or better.5 These results are similar
to those achieved by Tuefert and De La Cruz,6 although
the number of patients who maintained an air-bone gap
of 30 dB or less fell from 63.1% to 50% over time. Our
experience supports the fact that roughly two thirds of
patients achieve these thresholds. The risk for severe
sensorineural hearing loss related to atresia surgery is
2% to 7.5%.5,6
When hearing improvement does not exceed a 30-
dB speech reception threshold, some patients may wish
to use an in-canal type of hearing aid once healing
within the canal is complete. Typically, only a small
amount of amplifi cation is necessary to restore hearing
to acceptable levels, which is why the creation of a canal
alone has sometimes been helpful.
COMPLICATIONS
Canal restenosis and lateralization of the tympanic
membrane are by far the most common complications
after atresia surgery. Other complications include blunt-
ing of the tympanic membrane, sensorineural hearing
loss, and facial nerve injury. For an inexperienced
surgeon, the facial nerve is at its greatest risk in the
inferoposterior portion of atretic bone just lateral to
the middle ear.8 Facial nerve problems occur much less
frequently because intraoperative facial nerve monitor-
ing is now routine.
Stenosis in the midcanal area seems to take place
only in unepithelialized areas in which bare bone per-
sists. If early signs of canal stenosis are evident on post-
operative follow-up, gentle stenting and dilatation of
the canal will usually limit the extent of stenosis. Any
areas of granulation within the canal should be aggres-
A
B
Figure 111-17. A and B, Elevation and elimination of the canal
stenosis.
Once this has been completed satisfactorily, the ear is
thoroughly irrigated to remove all bone dust. Middle
ear exploration is advised if preoperative audiometric
testing indicates a conductive hearing loss greater than
the 20 to 30 dB expected for canal atresia alone.
Generally, little skin can be salvaged from the canal
in such cases because the soft tissue is composed almost
entirely of scar tissue. For this reason, a skin graft is used
in the manner previously described for reconstructing
a congenital atretic canal. Once again, it is not prudent
to remove and replace skin from the external auditory
canal that is actively infl amed, such as in chronic exter-
nal otitis, because the same problem will usually recur.
Resolution of acute and chronic infl ammation should
be ensured before proceeding in this manner.

1122
Section 12
Otology
sively cauterized with silver nitrate and treated with
steroid-containing ototopicals.
In the case of midcanal or medial canal stenosis
after a previous attempt at tympanoplasty or mastoidec-
tomy, special precautions may be taken to prevent
recurrence. A steroid solution may be placed in the
packing at the time of surgery and a short course of oral
steroids given in the immediate postoperative period.
If despite these measures medial fi brosis begins again
in the postoperative period, triamcinolone acetonide
(Kenalog), 10 mg/mL, is injected with a 27-gauge
needle into the medial canal stenotic area. This will
usually prevent restenosis.
References
1. Becker BC, Tos M: Postinfl ammatory acquired atresia of the exter-
nal auditory canal: Treatment and results of surgery over 27 years.
Laryngoscope 108:903-907, 1998.
2. Slattery WH, Saadat P: Postinfl ammatory medial canal fi brosis. Am
J Otol 18:294-297, 1997.
3. Birman CS, Fagan PA: Medial canal stenosis—chronic stenosing
external otitis. Am J Otol 17:2-6, 1996.
4. Kountakis SE, Helidonis E, Jahrsdoerfer RA: Microtia grade as
an indicator of middle ear development in aural atresia. Arch
Otolaryngol 121:885-886, 1995.
5. Jahrsdoerfer RA, Yeakley JW, Aguilar EA, et al: Grading system for
the selection of patients with congenital aural atresia. Am J Otol
13:6-12, 1992.
6. Teufert KB, De La Cruz A: Advances in congenital aural atresia
surgery: Effects on outcome. Otolaryngol Head Neck Surg 131:263-
270, 2004.
7. Jacobsen N, Mills R: Management of stenosis and acquired atresia
of the external auditory meatus. J Laryngol Otol 120:266-271,
2006.
8. Jahrsdoerfer RA, Lambert PR: Facial nerve injury in congenital
aural atresia surgery. Am J Otol 19:283-287, 1998.
PEARLS
• In the absence of any identifi able ear canal in an
atretic ear, drilling should always begin at the level
of the linea temporalis, just posterior to the glenoid
fossa.
• Lateralization of the tympanic membrane graft in
atresia surgery is best prevented by tucking a small
fl ap of fascia anteromedial to the bony annulus or
under the malleus handle.
• Blunting in the anterior sulcus is minimized by
creating a good bony annulus to seat the fascial
graft, minimizing the amount of skin-fascia overlap
medially, and tightly packing the anterior sulcus
with a Silastic disc over the tympanic membrane.
• Meatal stenosis is prevented by creating a large
meatus 1.5 times the normal size and careful
suturing of the lateral margins of the skin graft to
the newly created meatus to facilitate early healing
in this area.
• Patients who are poor surgical candidates for
atresia repair may be rehabilitated with a BAHA,
provided that their underlying cochlear reserve is
40 dB or less in the better-hearing ear, and microtia
repair is not planned in the future.
Figure 111-18. Axial computed tomography scan showing the
facial nerve coursing over the oval window.
• The most common causes of sensorineural hearing
loss after atresia are drilling on the ossicular chain
and overzealous manipulation of the ossicular chain.
• The presence of any active dermatologic condition
involving the meatus and canal at the time of atresia
repair will compromise healing and result in
restenosis of the canal.
• Soft tissue stenosis of the ear canal often results
from nonepithelialized bone within the ear canal.
PITFALLS
• An aberrant facial nerve that crosses the oval
window will increase the risk of trauma to the nerve
at the time of ossiculoplasty (Fig. 111-18).
• Failure to mobilize the entire ossicular chain before
tympanic membrane grafting will result in residual
postoperative conductive hearing loss.

section 13
Tympanic Membrane, Middle
Ear, and Mastoid
Chapter 112
Otitis Media, Myringotomy, and
Tympanostomy Tubes
Barry E. Hirsch
The middle ear is an air-containing space in which the
pressure is equalized to that of the outside atmosphere
via the eustachian tube. Most of the pathology occur-
ring in the middle ear and mastoid results from eusta-
chian tube dysfunction. Some of the acute and chronic
middle ear disorders can be reversed or prevented by
temporary or permanent ventilation via myringotomy,
with or without a tube.
Return of normal middle ear aeration is most fre-
quently needed in the pediatric population. Children
are predisposed to middle ear problems because of
eustachian tube dysfunction with subsequent otitis
media with effusion and recurrent acute otitis media.
Indications for placement of tympanostomy tubes in
children remain highly controversial. Some physicians
advocate that pediatric patients with otitis media
with effusion be managed with prophylactic or multiple
courses of antibiotics or simple observation. Such
management is controversial because of the threat of
delayed language development during these formative
years.
Over a decade ago, guidelines were proposed to
provide a management algorithm for otitis media with
effusion. Until recently, the indications for myringot-
omy with or without tube placement for otitis media
with effusion were not critically defi ned. Clinical prac-
tice guidelines were developed by a subcommittee of
experts from the American Academy of Pediatrics,
American Academy of Family Physicians, and American
Academy of Otolaryngology–Head and Neck Surgery.
They stated that identifi cation of serous otitis media
does not require antibiotics or removal of the fl uid.
Effort needs to be made to distinguish children who are
at risk for speech, language, or learning problems and
provide appropriate intervention. Those who are not at
risk can be observed for 3 months from the date of
onset or diagnosis. If hearing loss, language delay, or
learning problems are suspected, hearing testing should
be conducted. If sequelae are not identifi ed, the chil-
dren can be re-examined at 3- to 6-month intervals.
Once surgery becomes indicated, insertion of a tympa-
nostomy tube is the preferred initial treatment. Ade-
noidectomy is reserved for patients who require repeat
surgery. It was also concluded that antihistamines and
decongestants are ineffective for otitis media with effu-
sion. Furthermore, antimicrobials and corticosteroids
do not have long-term effi cacy and should not be used
for routine management.1
1123

1124
Section 13
Tympanic Membrane, Middle Ear, and Mastoid
LASER MYRINGOTOMY
The use of lasers in the practice of medicine has had
direct application in otology. Laser myringotomy was
proposed as a safe method to ventilate the middle ear.
It is not clear whether laser myringotomy is an effective
alternative to ventilation tubes. Koopman and associ-
ates conducted a randomized trial comparing laser my-
ringotomy with ventilation tubes in children who had
otitis media with effusion.2 The mean time until closure
of the laser perforation was 2.4 weeks, as opposed to a
mean of 4 months with tubes. The success rate was 40%
for the laser and 78% for tubes. We have not found
laser myringotomy to be of clinical benefi t in the treat-
ment of eustachian tube dysfunction, and we have con-
tinued the use of myringotomy knives for opening the
middle ear to provide ventilation.
Other clinical situations warrant removing fl uid
from the middle ear space or providing aeration. Factors
that infl uence such treatment include the age of the
patient, the nature of the pathology, the likelihood of
persistent eustachian tube dysfunction, and the appear-
ance of the tympanic membrane. Whether myringot-
omy alone or with tube placement is performed is also
dictated by the clinical situation. In this chapter some
of the more common indications for middle ear aera-
tion or drainage are reviewed.
VACCINATION
The potential role of enhanced immunologic surveil-
lance against the bacteria associated with otitis media
raises the question of whether immunizations would
decrease the need for myringotomy and tubes. Prevnar
is a pneumococcal heptavalent conjugate vaccine that
has been approved for use in children younger than 24
months. The prevalence of resistance to oral antibiotics
emphasized the need to seek other methods of prevent-
ing acute otitis media. A study by Caspary and colleagues
revealed that children vaccinated with Prevnar were two
times less likely to have non–Streptococcus pneumoniae
isolated from the middle ear. Children who were vacci-
nated were three times as likely to be infected with
Haemophilus infl uenzae, but these strains produced β-
lactamase less often.3
The most common organisms isolated from effu-
sions in the middle ear are S. pneumoniae and Moraxella
catarrhalis. The yield for identifi cation through routine
culture techniques is approximately 25%. There is
further evidence that otitis media with effusion is associ-
ated with persistent bacterial infection in the absence
of positive culture.
The development of biofi lms is hypothesized to be
the reason that otitis media with effusion is recalcitrant
to antibiotic treatment. Biofi lms are described as a col-
lection of bacteria coated by an extracellular matrix,
which may effectively protect the bacteria from penetra-
tion by the antibiotic. A recent study investigated
whether chronic otitis media is related to biofi lms.
Biopsy of ear mucosa was performed and fl uid aspirated
from 26 children undergoing placement of tympanos-
tomy tubes. Using polymerase chain reaction–based
diagnostics, at least one otitis media pathogen was posi-
tively identifi ed in 24 of 24 effusions. Confocal laser
scanning microscope images were obtained from middle
ear mucosa biopsy specimens. By using organism-spe-
cifi c probes for the three most common bacteria,
mucosal biofi lms were visualized on 46 of 50 (92%) of
the specimens. This information may change the phi-
losophy on how best to medically manage chronic otitis
media.4
PATIENT SELECTION
The indications for tympanocentesis, myringotomy, or
myringotomy with tube placement are individualized
for specifi c manifestations of eustachian tube dysfunc-
tion and middle ear pathology. The choice of proce-
dure and the design of the myringotomy tube are based
on the anticipated needs of the patient’s middle ear
problems. Hearing loss is the primary symptom for
which ventilation of the middle ear is needed. Clinical
situations can be characterized under the headings
of otitis media with effusion (children and adults),
acute otitis media, craniofacial abnormalities, baro-
trauma, otitis media and sepsis, and chronic eustachian
tube dysfunction.
Otitis Media with Effusion
Children
Otitis media with effusion is probably the most common
and most controversial pathologic condition for which
tympanostomy tubes are placed. The immature devel-
opment of the eustachian tube and the frequency at
which children are exposed to pathologic organisms
account for the higher incidence of middle ear effusion
in this age group.
Parents may notice children pulling at their ear or,
if old enough, complaining of ear discomfort. Audio-
metric and tympanometric screening tests performed
in daycare centers and elementary schools have identi-
fi ed young children with hearing impairment and
abnormal mobility of the tympanic membrane, respec-
tively. Appropriate referral to a pediatrician or otolar-
yngologist will determine whether signifi cant tympanic
membrane, middle ear, or inner ear disease is present.
Examination of the ear frequently reveals a dull,
retracted tympanic membrane that is opaque or amber.
Pneumatic otoscopy is often the most helpful technique
for confi rming lack of tympanic membrane mobility. A
fl at tympanogram also supports the diagnosis. However,
we rely primarily on physical examination and rarely
fi nd this adjunctive diagnostic test to be necessary. An
audiogram is obtained to determine the type and degree
of hearing loss (conductive, sensorineural, or mixed).
Otitis media occurs in 40% to 70% of preschool
children. However, otitis media with effusion frequently
resolves within 3 months with or without the use of sys-
temic antibiotics.5 There are a few algorithms that are
used in the management of otitis media with effusion.
An option for medical therapy consists of three courses

Chapter 112
Otitis Media, Myringotomy, and Tympanostomy Tubes 1125
of antimicrobial therapy given for 10 days at a time,
separated by one month. Another method of treatment
is long-term, low-dose antibiotic prophylaxis. Children
who have bilateral ear disease with signifi cant hearing
impairment and in whom medical treatment has failed
are candidates for tympanostomy tubes. In a child
younger than 6 months, it may be diffi cult to accurately
assess hearing thresholds. Other methods for determin-
ing hearing loss include parents’ observation of behav-
ioral manifestations of hearing loss, such as sitting close
to a television set, requesting higher listening volumes,
poor school performance, inattentiveness, or failure to
meet milestones for language development. If it is
determined that one ear is involved and the contralat-
eral ear is normal and if the hearing loss appears to be
minimal, continued observation may be prudent in
children younger than 3 years.
Adults
Otitis media with effusion occurs in adults as well as
children. Adults with a history of recurrent childhood
infections may have borderline eustachian tube dys-
function throughout their adult years. These people
may have diffi culty achieving middle ear aeration after
an airplane fl ight or, more commonly, after an upper
respiratory tract infection. Patients will complain of uni-
lateral or bilateral ear “stuffi ness,” occasional popping
sensations in the ear, and hearing loss. Examination of
the ear reveals a retracted tympanic membrane that
may be dull or amber. Pneumatic otoscopy, especially
when used with the operating microscope, facilitates
identifi cation of fl uid in the middle ear. Tuning fork
testing may confi rm a conductive hearing loss. If a
patient complains of new-onset hearing loss that appears
to be conductive and one is uncertain whether the
middle ear contains fl uid, diagnostic myringotomy will
provide a diagnosis.
Patients with new-onset unilateral or bilateral serous
effusions must undergo a complete examination of the
head and neck. To provide comprehensive care, one
must determine the cause of the effusion. New-onset
unilateral or bilateral serous effusion of the middle ear
may be a manifestation of eustachian tube dysfunction
resulting from pathology in the nasopharynx. Marked
adenoid hypertrophy or a neoplasm in the nasophar-
ynx, such as nasopharyngeal carcinoma or lymphoma,
can obstruct the eustachian tube orifi ce and cause
serous effusion. Tumors of the infratemporal fossa and
petrous apex may compress the eustachian tube. Fluid
in the middle ear may also result from sinonasal allergic
rhinitis. In particular, attention is directed to the naso-
pharynx. If examination with a mirror is inadequate,
fl exible fi beroptic or rigid nasopharyngoscopy is
necessary.
If examination of the tympanic membrane reveals
air bubbles within the middle ear space or air-fl uid
levels, aeration with a Valsalva maneuver or politzeriza-
tion is attempted. These tests may also be facilitated by
vasoconstriction of the nasal mucosa with topical oxy-
metazoline (Afrin). If the middle ear can readily be
ventilated by either of these maneuvers, observation is
warranted. Additional medical treatment with oral
decongestants, short-term vasoconstrictive nasal sprays,
or intranasal steroid sprays should be provided.
However, if the patient is unable to ventilate the ear,
myringotomy alone is performed. A tube is not neces-
sary for patients seen for the fi rst time with otitis media
with effusion. Patients known to have a longstanding
history of chronic eustachian tube dysfunction will
probably require a tympanostomy tube.
Acute Otitis Media
Acute otitis media is also a disease most common to
pediatric patients, although adolescent and adult
patients may experience this painful infection as well.
Symptoms of hearing loss, unilateral ear pain, and fever
are typical of this acute infection. Systemic antibiotics
are usually effective in reversing the infectious and
infl ammatory process. However, symptomatic relief
may require 24 to 72 hours. Myringotomy alone pro-
vides immediate relief from distention of the tympanic
membrane secondary to an abscess in the middle ear
space. A tympanostomy tube is not necessary in this
clinical situation.
Another manifestation of eustachian tube dysfunc-
tion in children is recurrent acute otitis media. This
condition generally responds to oral antibiotics with
clearing of the subsequent serous effusion. Prophylaxis
with daily doses of antibiotics is an alternative strategy
for medical management. Tympanostomy tube place-
ment should be considered in patients who experience
multiple recurrent infections despite appropriate
medical therapy. In addition, if the infections become
burdensome to the patient and parents or if the child’s
academic performance, school attendance, and physi-
cal health are repeatedly being compromised, tympa-
nostomy tubes should be advocated.
Acute Otitis Media with Complications
Despite the relatively common occurrence of acute
otitis media, complications associated with this infec-
tion are rare. Such complications include mastoiditis,
meningitis, brain abscess, and facial paralysis. Along
with systemic antibiotics, wide myringotomy with tube
placement is warranted in this acute setting. This pro-
vides middle ear ventilation to facilitate decompression
of the pressure and drainage of toxins affecting the
facial nerve.
Craniofacial Abnormalities
The eustachian tube is rendered dysfunctional in
numerous craniofacial abnormalities. A fl attened
cranium maintains the orientation of the eustachian
tube in a horizontal plane, which may impede normal
eustachian tube function. Patients with trisomy 21
abnormalities characteristically have poor tubal func-
tion and require myringotomy tubes. Similarly, patients
with compromised soft palate function secondary to a
cleft palate or tumor resection have a dysfunctional
eustachian tube opening that predisposes them to
middle ear fl uid and disease. Patients with such abnor-

1126
Section 13
Tympanic Membrane, Middle Ear, and Mastoid
malities should be screened early in life for compro-
mised eustachian tube function.
Barotrauma
Patients requiring hyperbaric oxygen therapy for disor-
ders other than carbon monoxide intoxication may
experience eustachian tube dysfunction. Consultation
with an otologist may be requested for patients with
pain or hearing loss during hyperbaric oxygen therapy.
Typically, these patients have wound-healing problems
that require 2 to 3 weeks of treatment. Medical manage-
ment of their “middle ear squeeze” usually consists of
oral and topical decongestants, along with slowing the
rate of rise in pressure in the chamber. If pain or
hearing loss still persists, tympanostomy tube placement
is warranted.
Sepsis and Otitis Media
The ears and sinuses of hospitalized patients who are
systemically ill with no obvious cause for their fever are
often evaluated as a potential source. Consultation is
frequently requested for patients with fl uid signal from
the middle ear as seen on magnetic resonance imaging
(MRI) or computed tomography (CT) of the head and
temporal bones. Should an effusion or obvious infec-
tion be identifi ed, myringotomy with culture or tympa-
nocentesis may be warranted.
Chronic Eustachian Tube Dysfunction
In patients with a longstanding history of eustachian
tube dysfunction, an atrophic, retracted, fl accid tym-
panic membrane that is hypermobile may develop.
Retraction may predispose to the formation of pockets
extending posteriorly toward the sinus tympani or supe-
riorly toward the epitympanum. The tympanic mem-
brane may drape over the ossicular chain and create a
natural type II or III tympanoplasty (Fig. 112-1).
Further progression of these retraction pockets
may promote the formation of cholesteatoma. Place-
ment of a tympanostomy tube will eliminate the nega-
tive middle ear pressure and minimize the likelihood
of further progression.
PREOPERATIVE PLANNING
Otitis Media with Effusion
The parents of children who are candidates for place-
ment of tympanostomy tubes should be given the
chance to review the indications, operative procedure,
and postoperative management of tube placement.
Unless it is an older, mature child, the procedure is
typically performed under general oral anesthesia.
Ideally, an audiogram should be obtained before tube
placement, but this may not be feasible in a very young
child. Patients with recurrent acute otitis media requir-
ing tube placement are managed similarly.
Patients with extremely small external auditory
canals may require myringotomy tubes that are not nor-
mally stocked. Stenotic canals may permit only a straight
tympanostomy tube with a very small inner fl ange.
Should it be anticipated that a smaller tube is necessary,
a call to check on the operating room tube inventory is
warranted. Placement of myringotomy tubes in adults
is typically performed in the clinic under topical anes-
thesia. The instruments and technique are described
later in this chapter.
Acute Otitis Media
Both pediatric and adult patients will benefi t from my-
ringotomy when they experience severe pain from
acute otitis media. Topical anesthesia applied to an
infl amed tympanic membrane may not be effective. An
adult, however, is better able than a child to cope with
myringotomy. Nursing assistance may be necessary to
restrain or wrap the child in a sheet.
Myringotomy is also performed for diagnostic eval-
uation of otitis media. The predominant indications are
a child with persistent acute otitis media in whom anti-
biotic therapy fails or any person who may be immuno-
compromised when identifi cation of the organism is
important for appropriate management. Myringotomy
provides prompt relief of fullness, pressure, pain,
and hearing loss in persons with acute otitis media
unresponsive to antibiotics. When identifi cation of
the organism is critical, a Senturia trap is used for diag-
nostic tympanocentesis. In clinical situations in which
the bacteriology of the middle ear effusion must be
known, appropriate planning is necessary. Communica-
tion with the patient’s physician and microbiology
laboratory will expedite handling of the aspirated
specimen.
Patients with acute otitis media who experience
complications such as facial paralysis, mastoiditis, or
meningitis require imaging to detect any other intracra-
nial complications. Along with CT or MRI, neurosurgi-
cal consultation is warranted should an intracranial
abscess be identifi ed. Administration of intravenous
Figure 112-1. Severe atelectasis with a natural type II/III tympano-
plasty. Ventilation of the middle ear aims to lateralize the tympanic
membrane off the promontory and ossicles.

Chapter 112
Otitis Media, Myringotomy, and Tympanostomy Tubes 1127
antibiotics with close monitoring in a hospital is neces-
sary. If coalescent mastoiditis is present, mastoidectomy
along with a wide myringotomy and tube insertion
should be performed.
Choice of Tubes
The tympanostomy tube is placed through an incision
in the tympanic membrane to aerate the middle ear.
Depending on the nature of the middle ear pathology,
short- or long-term ventilation may be needed. Given
the patient’s fi ndings and previous otologic history,
along with the anticipated need, one may then decide
how long ventilation will be necessary. The variety of
tube designs and material available allows ventilation of
the middle ear from a few weeks to indefi nitely. Adult
patients with new-onset otitis media with effusion who
require ventilation should undergo placement of a tube
that would remain in place from a few weeks to 3
months. Patients who meet this criterion are those who
have persistent serous otitis media despite myringotomy
drainage. In addition, patients who have recently under-
gone otologic surgery and are having problems with
aeration may need short-term ventilation while the
middle ear and eustachian tube recover. Such ventila-
tion consists of a straight polyethylene tube for which
the medial fl ange has been removed (Fig. 112-2). The
tip of the tube is beveled to facilitate insertion.
Tubes with an inner fl ange remain in the tympanic
membrane and middle ear space for a longer time. A
Tytan tube provides middle ear ventilation for 4 to 6
months. If more time is needed for additional ventila-
tion, a grommet tube is used. The long-term results of
using Armstrong beveled grommet tubes in children
were reported by Lindstrom and coauthors. The median
and mean times to extrusion were 16.5 and 15.5 months,
respectively. The incidence of perforations that did not
resolve was 1.32%. Tubes were retained longer than 2
years in 12.2% of the patients.6 We prefer the design of
the Armstrong beveled grommet tube (Fig. 112-2).
Should ventilation of the middle ear be required
indefi nitely, other tubes are available. A Per-Lee tube
has a soft Silastic shaft attached to a large fl exible
middle ear fl ange. When placed through the tympanic
membrane, this tube will last for many years. The Goode
T tube also provides long-term ventilation. Figure 112-3
demonstrates the Per-Lee and Goode T tubes. The phy-
sician and patient must be aware that extrusion of the
tube may lead to a residual perforation in the tympanic
membrane. In the fi rst edition of this text we described
the use of a tube composed of hydroxyapatite, which
we no longer use.7
SURGICAL TECHNIQUE
Tympanocentesis
Tympanocentesis is performed when an infectious
agent is believed to be the cause of otitis media. The
external auditory meatus is carefully cleaned of cerumen
or keratin debris. Concomitant otitis externa with a
serous discharge requires further cleaning with a small
suction device or a cotton-tipped applicator, or both. If
bacterial or fungal colonization in the external meatus
is suspected, the canal is fl ushed with 95% alcohol.
Once the canal is suctioned free of this solution and it
has dried, tympanocentesis is performed. In a coopera-
tive adult, a small (2 to 3 mm) dot of phenol is applied
to the tympanic membrane to provide local anesthesia.
Either the posteroinferior or the anterior quadrants are
readily accessible for this procedure (Fig. 112-4).
Children
Children warranting ventilation with tubes routinely
require general anesthesia for insertion of the tube.
Once general oral anesthesia has been induced, the
operating microscope is positioned and the ear exam-
ined. With an ear loop, small cotton-tipped applicator,
suction device, or alligator forceps, the ear is cleaned
of cerumen. We prefer to place the myringotomy tube
in the anterior or anterosuperior quadrant (Fig. 112-5).
These areas retain a tube longer because of the migra-
tion pattern of the epithelium of the tympanic mem-
brane. After the myringotomy, a 5F suction device is
used to evacuate fl uid from the middle ear. Thicker
Figure 112-2. Tympanostomy tubes frequently used for middle ear
ventilation: left, Tytan tube with a 0.76-mm inner diameter (ID)
(Medtronics, Inc.); center, straight-shank tube (Micromedics); right,
Armstrong modifi ed beveled grommet, 1.14-mm ID (Medtronics,
Inc.).
Figure 112-3. Long-term ventilation tubes: left, Per-Lee 600 fl ange
angled vent tube, 1.5-mm inner diameter (ID) (Medtronics, Inc.);
center, Goode T tube, 1.14-mm ID, 6-mm length; right, Goode T tube
modifi ed, 1.27-mm ID, 4.5-mm length (Medtronics, Inc.).

1128
Section 13
Tympanic Membrane, Middle Ear, and Mastoid
malleus. The former may result in marginal perforation
and the latter in pulsatile tinnitus.
An antibiotic-steroid drop is instilled into the ear if
the middle ear had mucoid fl uid, excessive serous fl uid,
or a purulent collection. In addition, unwarranted
bleeding merits the use of drops to minimize the likeli-
hood of tubal obstruction.
Adults
Most teenagers and adults tolerate myringotomy and
tube placement under local anesthesia in an offi ce
setting. The patient is informed about the indications
for tube placement, and the potential risks of inserting
and having a myringotomy tube in place are discussed.
Operative consent is obtained. The instruments needed
for the procedure are prepared. Instruments that
should be available include an applicator wrapped with
a wisp of cotton, topical phenol, a myringotomy knife,
a suction tip, alligator forceps, and a fi ne micropick to
facilitate myringotomy tube positioning should it be
necessary (Fig. 112-7).
The ear canal is cleaned under the operating micro-
scope. Ideally, the tube is placed in the anterior aspect
of the tympanic membrane. On occasion, because of
the prominent convexity of the anterior bony canal
wall, access to the anterior tympanic membrane is
limited. In this situation a myringotomy tube is placed
in the posteroinferior quadrant. Topical anesthetic
(phenol applied to a fi ne cotton-tipped applicator) is
placed on the lateral surface of the tympanic mem-
brane. A myringotomy is performed, and fl uid is aspi-
rated from the middle ear. The ventilation tube is
inserted and optimally positioned.
Topical anesthesia is occasionally insuffi cient, pos-
sibly because of the patient’s intolerance to manipula-
tion of the ear or narrowness of the ear canal. After
Figure 112-4. Tympanocentesis of the inferior tympanic mem-
brane with a Senturia trap. (From Bluestone CD: Otologic surgical proce-
dures. In Bluestone CD, Stool SE [eds]: Atlas of Pediatric Otolaryngology.
Philadelphia, WB Saunders, 1995, p 31.)
Figure 112-5. Myringotomy is performed in the anterosuperior
quadrant. (From Bluestone CD: Otologic surgical procedures. In Bluestone
CD, Stool SE [eds]: Atlas of Pediatric Otolaryngology. Philadelphia, WB
Saunders, 1995, p 33.)
secretions may require suctioning with a 7F suction
device. If fl uid removal proves diffi cult, a second my-
ringotomy is performed in the posteroinferior quad-
rant to better ventilate the ear. Once the fl uid is
evacuated, the size of the myringotomy is noted. If the
myringotomy site is inadequate, it can be enlarged with
the myringotomy knife. Alligator forceps may also be
opened in the myringotomy site to dilate the incision.
A grommet tube is typically inserted in children requir-
ing such ventilation (Fig. 112-6). Once a grommet tube
is placed, its proper location and orientation are veri-
fi ed. One should avoid placing the myringotomy tube
right at the annulus or immediately adjacent to the
Figure 112-6. An Armstrong beveled grommet tube is placed after
aspiration of fl uid in the middle ear. (From Bluestone CD: Otologic surgi-
cal procedures. In Bluestone CD, Stool SE [eds]: Atlas of Pediatric Otolaryngol-
ogy. Philadelphia, WB Saunders, 1995, p 35.)

Chapter 112
Otitis Media, Myringotomy, and Tympanostomy Tubes 1129
informing the patient, a local anesthetic consisting of
1% lidocaine (Xylocaine) with 1:100,000 epinephrine
is infi ltrated into the external canal. Topical phenol is
also placed to cauterize the drum and minimize bleed-
ing. Patients are advised that the tongue may feel tem-
porarily numb on the side of the injection.
Patients requiring ventilation for an indefi nite
period are usually taken to the operating room for tube
placement under the operating microscope. Our fi rst
choice is a T tube, given its relative ease of insertion and
lower incidence of tympanic membrane perforation
after extrusion. The Per-Lee tube provides indefi nite
middle ear ventilation. The large fl ange of a Per-Lee
tube is trimmed. Myringotomy is performed in the ante-
rior aspect of the tympanic membrane. The fl anges of
the Per-Lee tube are folded on themselves with alligator
forceps, and the tube is advanced into the middle ear
(Fig. 112-8). It is often necessary to use middle ear
hooks or picks to facilitate tucking the fl anges of the
tube medial to the tympanic membrane. In the fi rst
edition of this text we mentioned using the Jahn
hydroxyapatite tube for long-term ventilation. This tube
requires a lengthier procedure for proper placement.
It was necessary to elevate an inferior tympanomeatal
fl ap to drill a trough in the bony tympanic ring for
placement of the tube in the middle ear. Problems
encountered with this tube included the development
of organized occlusion of the lumen of the tube that
defi ed achieving patent communication from the
ear canal to the middle ear. In addition, the shaft of
the tube became incorporated into the bony tympanic
ring, and a surgical drill was required to remove the
tube.
POSTOPERATIVE MANAGEMENT
Myringotomy and placement of tympanostomy tubes
are usually done in the offi ce in adults with serous otitis
media. Patients are advised that some drainage may
occur. A cotton ball is placed in the external meatus.
Once drainage has ceased, patients are instructed to
leave the ear open to air.
All patients, including children and adults, are
instructed to keep their ears dry. Patients are particu-
larly advised to minimize water exposure while shower-
ing or swimming. During showering, a cotton ball with
petrolatum (Vaseline) placed on its medial surface is
recommended for water protection. We permit swim-
ming with tympanostomy tubes in place. Again, however,
precautions are still given to minimize water exposure.
We advocate the use of ear plugs for swimming (e.g.,
silicone putty, a molded ear plug, Doc’s Proplugs). The
latter has been most effective for protecting the ear
during showering and swimming.
Patients undergoing myringotomy tube placement
for purulent otitis media, mucoid effusion, or blood
coming through the tube from the middle ear are
instructed to use topical antibiotic eardrops to mini-
mize the likelihood of tube obstruction from inspis-
sated secretions or dried blood. Parents or patients are
advised to use 4 to 5 drops of a quinolone ear prepara-
tion twice a day. Children receiving myringotomy tubes
are usually checked within a few weeks of placement.
The position and patency of the tube are verifi ed.
Patients are seen every 4 to 6 months, depending on
the ear pathology.
Postoperative tympanostomy tube otorrhea occurs
in approximately 20% of untreated children. In a study
comparing topical ciprofl oxacin/hydrocortisone and
neomycin/polymyxin B/hydrocortisone with no treat-
ment, it was noted that there was less otorrhea in the
treated ears than in the untreated ears. Given the pro-
phylactic effi cacy of drops, it was recommended that
the quinolone preparation be used because of its lack
Figure 112-7. Instruments needed for placement of a myringot-
omy tube in the offi ce (from left to right): fi ne alligator forceps,
myringotomy knife, phenol, fi ne micropick, suction tip, and applica-
tor wound with a wisp of cotton.
Figure 112-8. The fl ange of a Per-Lee tube has been trimmed,
folded on itself, and grasped with alligator forceps in preparation for
insertion. A wide myringotomy has been incised to fi t the larger
tube.

1130
Section 13
Tympanic Membrane, Middle Ear, and Mastoid
of ototoxicity.8 As a result of the broad spectrum of
coverage provided by quinolones, they are the medica-
tion of choice when tube otorrhea develops. Other
factors that may contribute to otitis media and otorrhea
include exposure to other children in daycare and to
second-hand smoke.
Persistent drainage despite the use of topical ear-
drops warrants microscopic evaluation of the ear. Puru-
lent material draining through the myringotomy tube
should be cultured for identifi cation of the organism
and antibiotic sensitivity. The presence of polypoid
tissue implies a foreign body reaction to the tube or
keratin debris in or around the tube. Ototopical drops
containing steroids are often effective in reversing the
pathology, but persistent granulation tissue or polyp
formation will probably necessitate biopsy and removal
of the tube. CT may be appropriate to evaluate the
middle ear for cholesteatoma.
On occasion, granulation tissue may develop
around the outer fl ange of a myringotomy tube and
manifest as aural bleeding and localized infection. Man-
agement consists of removing the polyp with either a
suction device or cup forceps. Liquid silver nitrate is
applied with a fi ne cotton-tipped applicator to cauterize
the granulation tissue base. Topical eardrops are pre-
scribed for 1 week.
COMPLICATIONS
Myringotomy or placement of a myringotomy tube is
usually straightforward and without complications.
However, as with any surgical procedure, problems can
occur. One must determine that the observed pathol-
ogy merits myringotomy or a tube, or both. The indica-
tions mentioned include ventilation for retraction
pockets, middle ear effusion, aeration for barotrauma,
and conductive hearing loss in which the status of the
middle ear space is in question. If the tympanic mem-
brane is opaque or does not readily move, diagnostic
myringotomy is performed. However, caution must be
exercised to not confuse congenital or aberrant blood
vessels in the middle ear space with fl uid. In particular,
a dehiscent high-riding jugular bulb or aberrant carotid
artery may look like a blue or salmon effusion. Careful
inspection of the tympanic membrane should allow rec-
ognition of these unusual fi ndings. Similarly, a glomus
tumor may also be confused with acute otitis media with
effusion.
During myringotomy and tube insertion, caution
must be taken to not traumatize the canal wall. In par-
ticular, the anterior bony canal is covered with thin skin
that bleeds easily when abraded or lacerated. Should
this occur, a cotton wick impregnated with adrenaline
is placed in the ear canal for 5 minutes, and topical
eardrops are provided for 5 days.
Creating too large a myringotomy may also be a
problem. A tube placed in a large perforation may
readily fall into the middle ear. If the tube can be
removed through the myringotomy site, this effort
should be undertaken. Identifying a tube in the middle
ear behind an intact tympanic membrane does not
mandate removal of the tube (Fig. 112-9). Occasionally,
the tube may fall into the hypotympanum and make
access diffi cult unless a large tympanomeatal fl ap is
elevated. If the tube drops out of sight, it is best to not
blindly try to retrieve it. The patient or family should
be told of the complication and apprised of the rare
but potential problems, including chronic otitis media
or a sense of the object shifting with head movement.
This is unusual and surgical intervention is warranted
if patients are symptomatic. Preoperative imaging may
be useful in planning the procedure.
A large tympanic membrane defect may also occur
when a large suction device for aspiration is applied
to a severely atrophic tympanic membrane. There are
two options for management. One is to place Gelfoam
medial to the perforation and paper-patch the defect.
A second myringotomy and tube are then placed in the
posterior or posteroinferior quadrant. Another method
is to place the tube at a margin of the large perforation
and apply a paper patch to the remaining portion of
the defect.
In some patients the ear canal is exceedingly small.
This often occurs in children with trisomy 21 abnor-
malities. If the stenotic canal is small, a smaller tube is
often necessary. If a beveled grommet tube is preferred,
one is available in a smaller size. This smaller tube is
preferentially used in children younger than 3 months
or, again, in patients with very small ear canals. On rare
occasion the canal is so stenotic that only a straight tube
can be placed.
Myringotomy tubes should not be placed in the
posterosuperior quadrant. Concern for the ossicular
chain in this area demands that this quadrant not be
violated. A tube with short depth, such as a Tytan tube,
Figure 112-9. Right ear demonstrating a retained myringotomy
tube in the middle ear.

Chapter 112
Otitis Media, Myringotomy, and Tympanostomy Tubes 1131
may be placed carefully if the ear canal is so narrow that
this is the only quadrant visible.
Myringotomy tubes can become plugged. Diligent
care is required for patients who are prone to this
problem. In particular, patients with hydroxyapatite
tubes require meticulous attention. It is for this reason
that we no longer use this type of tube design. The
diameter of a 3F suction device is suffi ciently compara-
ble with that of the tube lumen to permit placement
within its lumen. A desiccated mucous plug may often
be removed in this fashion. Otherwise, a straight or
curved pick can be used to mobilize the plug to facili-
tate suctioning and extraction. On occasion, the plug
can also be pushed into the middle ear space. Patients
with mucoid effusions are susceptible to plugging the
lumen of their tube, which may be prevented with the
use of topical eardrops containing steroids.
Patients with poor eustachian tube function and a
retracted tympanic membrane may undergo myringot-
omy tube placement to improve ventilation. Sometimes,
there is a fi brous union between the incus and stapes.
Before myringotomy tube placement, a natural type
III tympanoplasty may exist (see Chapter 114), which
describes a tympanic membrane directly adherent to
the stapes. After placement of the tube, the tympanic
membrane may lateralize, thereby causing partial ossic-
ular disarticulation and increasing the air-bone gap.
Careful inspection of the incudostapedial area may
identify this potential problem. Although rare, patients
are advised that hearing may actually deteriorate after
tube placement.
Despite the presence of fl uid in the middle ear and
mild conductive hearing loss, patients may not acknowl-
edge improved hearing after tube placement. Immedi-
ately after tube placement, patients may complain of a
hollow sound or describe their hearing as though they
“are in a barrel.” They are reassured that this is a short-
lived problem and that hearing will sound more normal
by the next day.
After myringotomy tube extrusion, a perforation in
the tympanic membrane may persist. If additional time
for middle ear ventilation is necessary, the perforation
functions like a myringotomy tube. However, a persis-
tent perforation may need to be repaired with either a
paper patch or formal tympanoplasty (see Chapter
113).
Post-tympanostomy tube otorrhea (PTTO) occur-
ring within 2 weeks of placement is considered an early
complication. Its reported incidence is between 5% and
49%. Late PTTO occurs greater than 2 weeks postop-
eratively and is caused by the same mechanism as for
acute otitis media and by external contamination. It has
been noted to develop in 26% of patients. Chronic
PTTO refers to otorrhea lasting longer than 8 weeks
and has an incidence of 4%.1 Some of the factors that
may predispose to PTTO include children in an urban
setting, lower socioeconomic status, repeated exposure
to unrelated children (daycare), and the presence of
mucoid or purulent effusions at the time of placement
of the tympanostomy tubes. In children older than 3
years, the bacteriology of the drainage mirrors the
organisms of acute otitis media: S. pneumoniae, H. infl u-
enza, M. catarrhalis, and Streptococcus pyogenes. The inci-
dence of Pseudomonas aeruginosa and Staphylococcus
aureus is higher in children older than 3 years, and it
occurs with even greater frequency in the summer
months.9
PEARLS
• Myringotomy without a tube may be more
appropriate if the compromise in middle ear
aeration is only short lived.
• Do not place a myringotomy tube in the posterior
superior quadrant to avoid the possibility of injury
to the ossicular chain.
• Use a wider-diameter tube and topical steroid
eardrops if mucoid fl uid is encountered in the
middle ear.
• When placing a myringotomy tube in the offi ce
setting, have a fi ne 1-mm right-angled pick available
to facilitate positioning of the tube.
• Persistent otorrhea, especially when granulation
tissue is present around the tube, may require
removal of the myringotomy tube.
PITFALLS
• Application of phenol or placement of a
myringotomy tube in an atrophic fl accid portion of
the tympanic membrane is more likely to result in
residual tympanic membrane perforation.
• Placing a myringotomy tube at the annulus or
juxtaposed to the malleus handle may lead to
marginal perforation or pulsatile tinnitus,
respectively.
• Aggressive aspiration of an atrophic tympanic
membrane through the myringotomy site with a
large-diameter suction device may result in
perforation at another area of the tympanic
membrane.
• Re-establishing aeration in an ear with severe
retraction, possible erosion of the incus, and a
natural type III tympanoplasty may cause greater
conductive hearing loss if the tympanic membrane
lateralizes away from the stapes.
• Hitting the promontory while placing a myringotomy
tube in a severely retracted tympanic membrane can
be avoided by placement in the anterior superior
quadrant, over the air space of the eustachian tube
opening.
References
1. Rosenfeld RM, Culpepper L, Doyle KJ, et al: Clinical practice
guideline: Otitis media with effusion. Otolaryngol Head Neck Surg
130(5 Suppl):S95-S118, 2004.

1132
Section 13
Tympanic Membrane, Middle Ear, and Mastoid
2. Koopman JP, Reuchlin AG, Kummer EE, et al: Laser myringotomy
versus ventilation tubes in children with otitis media with effusion:
A randomized trial. Laryngoscope 114:844-849, 2004.
3. Caspary H, Welch JC, Lawson L, et al: Impact of pneumococcal
polysaccharide vaccine (Prevnar) on middle ear fl uid in children
undergoing tympanostomy tube insertion. Laryngoscope 114:975-
980, 2004.
4. Hall-Stoodley L, Hu FZ, Gieseke A, et al: Direct detection of bacte-
rial biofi lms on the middle-ear mucosa of children with chronic
otitis media. JAMA 296:202-211, 2006.
5. Bluestone CD: Eustachian Tube: Structure, Function, Role in
Otitis Media. Ontario, BC Decker, 2005.
6. Lindstrom DR, Reuben B, Jacobson K, et al: Long-term results of
Armstrong beveled grommet tympanostomy tubes in children.
Laryngoscope 114:490-494, 2004.
7. Hirsch BE: Otitis media, myringotomy, and tympanostomy tubes.
In Myers EN (ed): Operative Otolaryngology: Head and Neck
Surgery. Philadelphia, WB Saunders, 1997, pp 1236-1245.
8. Morpeth JA, Bent JP, Watson T: A comparison of Cortisporin and
ciprofl oxacin otic drops as prophylaxis against post-tympanostomy
otorrhea. Int J Pediatr Otorhinolaryngol 61:99-104, 2001.
9. Oberman JP, Derkay CS: Posttympanostomy tube otorrhea. Am J
Otolaryngol 25:110-117, 2004.

Chapter 113
Myringoplasty and Tympanoplasty
Barry E. Hirsch
Myringoplasty and tympanoplasty are descriptive terms
defi ning surgical procedures that address pathology of
the tympanic membrane and the middle ear, respec-
tively. Myringoplasty is an operative procedure used to
restore the integrity of a perforated tympanic mem-
brane. This assumes that the middle ear space, its
mucosa, and the ossicular chain are free of active
disease. Inspection of the middle ear is undertaken
through the tympanic membrane. A tympanomeatal
fl ap is not raised and the middle ear is not directly
exposed. The only procedure performed is directed at
reconstruction of the tympanic membrane. In contrast,
tympanoplasty also implies reconstruction of the tym-
panic membrane but in addition deals with pathology
in the middle ear cleft, such as chronic infection,
cholesteatoma, or problems with the ossicular chain.
Zollner1 and Wullstein2 provided a classifi cation of tym-
panoplasty that focuses on the type of ossicular chain
reconstruction needed. This classifi cation is of histori-
cal interest because reconstruction of the ossicular
chain was not undertaken at that time. It does provide
a standardized method for analyzing pathology of the
ossicular chain and for reporting outcomes of middle
ear reconstruction. The fi ve types of tympanoplasty that
these authors described defi ne the status of the ossicu-
lar chain as a result of pathologic changes from eusta-
chian tube dysfunction and middle ear disease.
Progression from type I to type V describes the status
of the remaining ossicular chain. Type I has all ossicles
intact and requires reconstruction of only the tympanic
membrane. Type V consists of no ossicles and connec-
tion to the inner ear through a fenestrated horizontal
semicircular canal or the vestibule at the oval window.
A variety of symptoms and signs indicate the need
for either myringoplasty or tympanoplasty. Acute tym-
panic membrane perforation or lacerations may occur
as a result of local trauma, such as a hand slap to the
ear, from a misdirected cotton-tipped applicator
inserted in the external canal, or from barotrauma.
Another source of perforation of the tympanic mem-
brane is water compression, which can occur while
diving or falling onto a body of water with the ear
making direct contact with its surface. It can also occur
as a result of a wave hitting the ear while swimming or
as a consequence of forceful irrigation of the ear canal
during removal of cerumen. Patients with trauma to the
tympanic membrane typically complain of a sudden
onset of pain with associated hearing loss and occa-
sional bloody otorrhea. The tympanic membrane in
such cases may heal spontaneously or might require
myringoplasty only. In contrast, patients requiring tym-
panoplasty more often have a longstanding history of
hearing loss, perforation of the tympanic membrane,
and chronic otitis media with intermittent otorrhea.
Frequent otorrhea often implies chronic mastoid
disease, and mastoidectomy may be required.
This chapter focuses on repair of the tympanic
membrane. The indications and techniques of ossicular
chain reconstruction are covered in Chapter 114.
Pathologic processes requiring mastoidectomy, such
as chronic otitis media with or without cholesteatoma,
are addressed in Chapter 115.
PATIENT SELECTION
Indications for reconstruction of the middle ear and
tympanic membrane are to eliminate recurrent disease,
provide a dry ear canal and middle ear space with an
intact tympanic membrane, and maintain or improve
hearing. Achieving an intact tympanic membrane elimi-
nates the precautions that patients must take to avoid
potential contamination of the middle ear with water
and subsequent otorrhea.
Otologic management is dictated by the patient’s
symptoms and fi ndings. The status of the tympanic
membrane and eustachian tube function greatly infl u-
ences the alternatives for otologic care. Patients with
conductive hearing loss and an intact tympanic mem-
1133

1134
Section 13
Tympanic Membrane, Middle Ear, and Mastoid
brane who have an aerated middle ear or a clean dry
perforation have three options: (1) periodic observa-
tion and monitoring of hearing status, (2) surgical
reconstruction of the tympanic membrane, and (3)
amplifi cation with a hearing aid. Electing no further
treatment with a dry tympanic membrane perforation
incurs the risk of recurrent otorrhea after an upper
respiratory tract infection or contamination with water.
Patients should not swim or be exposed to water. If the
conductive hearing loss is greater than 30 to 35 dB, the
patient is often functionally compromised. Along with
reduced hearing in the ipsilateral ear, it may be diffi cult
to localize sound. Patients reluctant to undergo surgery
may opt for aural amplifi cation. Although the risks asso-
ciated with anesthesia and a surgical procedure are
avoided, problems inherent with hearing aid use must
be accepted, including the need to frequently replace
batteries, instrument malfunction, amplifi cation of
unwanted background noise, reduced hearing while
the hearing aid is out (such as during sleep), and occa-
sionally noisy feedback.
Perforation of the tympanic membrane does not
necessarily have to be accompanied by conductive
hearing loss. Small perforations, such as those seen
after extrusion of a myringotomy tube, may be associ-
ated with normal hearing, whereas a patient with a
nearly total perforation may have conductive hearing
loss of 35 to 40 dB. A similar loss in the setting of a small
perforation raises concern that the ossicular chain may
not be intact or may be fi xed. The surgeon must antici-
pate the potential need for reconstruction of the ossicu-
lar chain and have appropriate surgical instruments
and prostheses available at the time of surgery.
The presence of a mixed loss of hearing may alter
the advice given by the surgeon. Although surgical cor-
rection of conductive loss may close the air-bone gap,
a sensorineural component may still require amplifi ca-
tion. In this situation, surgery may not be in the patient’s
best interest. However, if severe mixed loss precludes
adequate gain and comfort from an ear-level aid, surgi-
cal correction of the conductive component would
better facilitate aural rehabilitation. The diagnosis of
otosclerosis must be considered when there is a history
of slowly progressive hearing loss, bilateral disease is
present, and the family history is positive. Surgical man-
agement of fi xation of the stapes footplate is addressed
in Chapter 117.
Examination of patients with a perforated tympanic
membrane via the microscope is helpful in revealing
the nature of the pathology. Inspection of the canal and
middle ear space may provide evidence of recurrent or
chronic otorrhea. The location of the defect in the
tympanic membrane may raise the surgeon’s suspicion
of cholesteatoma. Marginal perforations with thin
keratin migrating laterally from the edge (“trail sign”)
suggests squamous epithelium or cholesteatoma in the
middle ear. These fi ndings, along with hypertrophied
mucosa or extensive granulation tissue, suggest the
need for tympanoplasty with mastoidectomy. Tympano-
plasty without mastoidectomy would be considered if
recurrent drainage is infrequent.
The role of mastoidectomy in improving the success
rate of tympanic membrane grafting is controversial.
This issue was examined in a recent study. Similar success
was achieved in two groups of patients undergoing tym-
panoplasty in which the only variable was whether mas-
toidectomy was performed at the time of tympanoplasty.
Neither group had (1) active infection (active otorrhea,
abnormal middle ear mucosa, or granulation tissue),
(2) ossicular abnormalities (ossicular fi xation, ossicular
discontinuity, ossicular malformation, or absence of an
ossicle), (3) cholesteatoma, or (4) previous attempt at
tympanic membrane repair (previous tympanoplasty or
mastoidectomy). The authors noted that the need for
subsequent revision surgery was diminished in those
undergoing mastoidectomy at the initial procedure.3 It
is our opinion that tympanoplasty alone, without mas-
toidectomy, is indicated in patients with normal-appear-
ing mucosa in the middle ear. Despite a well-organized
preoperative plan, the surgeon must be prepared to
modify the surgical approach and technique based on
the intraoperative fi ndings.
Other issues can infl uence whether surgical inter-
vention is offered. The nature of the patient’s disease
and desire for intervention typically dictate the type of
rehabilitation recommended. An audiogram is always
obtained and typically repeated if the patient has not
been seen in the offi ce within 6 months. Along with the
physical examination, the hearing status of the contra-
lateral ear also infl uences the method of aural rehabili-
tation. A patient with mixed or conductive hearing loss
and a contralateral anacoustic ear is offered a hearing
aid unless the hearing ear has signifi cant active disease
unresponsive to medical management.
Collecting additional information and identifying
other fi ndings on physical examination may infl uence
the decision for or against surgical intervention. The
issue of timing of tympanoplasty, especially in children,
remains controversial. The status of the contralateral
ear may provide caution or reassurance that the eusta-
chian tube is functioning normally in the involved ear.
A recent study in children noted that a dry perforation
or the presence of a myringotomy tube in the contra-
lateral ear did not negatively affect successful tympanic
membrane repair in the ipsilateral ear. Poor prognostic
fi ndings included more objective evidence of ongoing
contralateral eustachian tube dysfunction, as evidenced
by otitis media with effusion or negative middle ear
pressure (atelectasis). Surgery in these children less
often resulted in an intact tympanic membrane and a
normal middle ear space.4
Operative reports of previous otologic procedures
performed on either ear should be reviewed. This may
provide insight into the status of eustachian tube func-
tion, because patients with tympanic membrane perfo-
ration who have undergone repeated tympanoplasty
procedures usually have poor tubal function. In addi-
tion, evaluating the status of contralateral middle ear
aeration and tubal function may predict the probable
success of yet another tympanoplasty.
Other physical fi ndings and symptoms may affect
the decision to surgically address the tympanic mem-

Chapter 113
Myringoplasty and Tympanoplasty 1135
brane and middle ear. Patients with cleft palate defor-
mities are prone to recurrent and chronic middle ear
infection. Symptoms such as vertigo should be investi-
gated to avoid operating on an ear that may have
ongoing vestibulopathy. If a patient has an actively
draining ear, every effort should be made to dry the ear
with topical drops or possibly systemic antibiotics, or
both. A dry ear before surgery increases the likelihood
of success. It is also important for the physician to know
whether the patient will be compliant and return for
follow-up care.
The risks and benefi ts of the planned operative
procedure must be explained. Potential complications,
although rare, include worsening of hearing or com-
plete hearing loss, vertigo, change in taste on the ipsi-
lateral side of the tongue, and failure of the graft to
heal. Taste disturbance results when the chorda tympani
nerve is stretched, desiccated, or divided. Patients may
remain symptomatic for 4 to 6 months. In some cases
this results in permanent dysfunction. Patients under-
going a postauricular approach should be told that the
top of the pinna often feels numb or there may be a
sense of “pins and needles” along the midhelix. Sensa-
tion usually returns in approximately 3 months.
PREOPERATIVE PLANNING
Imaging studies are not generally obtained before
routine myringoplasty or tympanoplasty procedures. If
readily available, the operative notes should be reviewed
if previous procedures were performed on the involved
ear. However, previous operative reports may not refl ect
the current situation in the middle ear and mastoid.
After numerous otologic procedures, local tissue for
grafting may not be readily available. If this is the case,
alternative sources such as perichondrium, periosteum,
or even areolar tissue or fascia from the contralateral
side should be considered. The integrity of the skin and
patency of the canal should be assessed. A split-
thickness skin graft may be necessary if canal atresia
or stenosis is present after previous procedures.
Before surgical intervention, informed consent must be
obtained.
ANESTHESIA
Tympanoplasty for reconstruction of the tympanic
membrane and correction of conductive hearing loss is
typically performed through a postauricular approach,
especially in patients with large or anterior perforations
and revision operations. Most of the procedures that we
perform entail lateral grafting techniques, usually per-
formed under general endotracheal anesthesia. Adult
patients who are reluctant to undergo general anesthe-
sia may be given a local anesthetic and regional block
supplemented with monitored intravenous sedation. In
cases of conductive hearing loss with an intact tympanic
membrane or a small perforation in which a medial
graft is anticipated, a transcanal approach is used. In
this case either local or general anesthesia may be con-
sidered. However, intravenous sedation with local anes-
thesia is preferred and typically well tolerated by the
patient. A sedated but awake patient with additional
local anesthesia presents distinct advantages during
ossicular reconstruction procedures. The surgeon can
assess the patient’s hearing result during the procedure
and detect any untoward symptoms, such as dizziness.
Antibiotic prophylaxis is not given for routine myringo-
plasty and tympanoplasty procedures.
SURGICAL TECHNIQUES
Medial and lateral grafting are probably equally success-
ful in the hands of experienced surgeons. Nevertheless,
we typically choose lateral grafting because of our con-
sistent results, which are in part due to the greater
exposure provided by this approach. A graft is placed
medially when the patient has an infrequent history of
otorrhea; when the perforation in the tympanic mem-
brane is small, not marginal, and located in the poste-
rior half of the tympanic membrane, or when there is
minimal evidence of middle ear disease. Myringoplasty
by defi nition addresses only the tympanic membrane in
patients in whom the ossicular chain is assumed to be
intact. Tympanoplasty techniques incorporate inspec-
tion of the middle ear and reconstruction of the ossicu-
lar chain when necessary.
An operative approach recently described for diffi -
cult or failed tympanoplasty procedures involves the use
of a palisading technique of cartilage and perichon-
drium. It may be indicated in patients with severe
atelectasis, in those with high-risk perforations and an
intact ossicular chain, and in association with ossiculo-
plasty when the malleus is present. High-risk perfora-
tion is defi ned as a tympanic membrane perforation
that persists after unsuccessful attempts at surgical
repair, a perforation anterior to the malleus, a perfora-
tion larger than 50%, or a bilateral perforation.5 Our
preference is not to use cartilage because inspection of
the middle ear to monitor for the recurrence or devel-
opment of cholesteatomas may be compromised. Carti-
lage is necessary when the scutum is eroded or removed
to access the epitympanum for mucosal disease and
cholesteatoma. Cartilage harvested from the tragus,
including an island of perichondrium, can help secure
the graft in its desired position.
Myringoplasty
Myringoplasty is performed for small or acute traumatic
perforations of the tympanic membrane. Acute trau-
matic tympanic membrane lacerations or perforations
require that the edges of the drum be unfolded to
remove squamous epithelium from the medial surface
of the tympanic membrane. Analgesia is often necessary
and is provided by a four-quadrant external canal block
applied just lateral to the cartilaginous-bony junction
with 2% lidocaine (Xylocaine) with 1:100,000 epi-
nephrine through a 27-gauge dental needle (Fig. 113-1)
(see Video 113-1). The edges of the tympanic mem-
brane perforation are unfolded so that not all squa-
mous epithelium is removed from the middle ear (Fig.
113-2). Often, approximation is not precise, and small

1136
Section 13
Tympanic Membrane, Middle Ear, and Mastoid
pieces of Gelfoam impregnated with a suspension of
ciprofl oxacin and hydrocortisone (Ciprodex) or plain
ciprofl oxacin solution (Floxin) is placed medial to the
laceration or perforation. A cigarette paper patch, Steri-
Strip, or silk patch is applied to the lateral surface of
the tympanic membrane (Fig. 113-3).
Small chronic perforations may also be treated by
lateral patching techniques. In this situation, topical
phenol or trichloroacetic acid is applied to the edges
of the perforation with a wisp of cotton on an applica-
tor. A sharp pick is then used to freshen the margins of
the tympanic membrane perforation to allow removal
of the edges of the perforation. This technique removes
any squamous epithelium that may have migrated under
the medial surface of the tympanic membrane at the
edge of the perforation and stimulates bleeding and
healing from the local vascular supply (Fig. 113-4). If
the perforation is small and the edges are well defi ned,
Gelfoam is not needed in the middle ear. A paper patch
is applied to the lateral surface of the tympanic
membrane.
Small central perforations may be reconstructed
with an autogenous tissue graft if paper patching is
unsuccessful. This technique requires similar prepara-
tion of the tympanic membrane while ensuring that no
squamous epithelium has migrated to the medial
surface of the edges of the perforation. Depending on
the age of the patient, myringoplasty with placement of
the graft medially can be performed in the operating
room under local anesthesia. Fat from the earlobe or
areolar tissue from the postauricular area is harvested,
compressed, and allowed to dry. After the edges of
the tympanic membrane perforation are freshened,
Figure 113-1. With a Lempert speculum, local anesthetic is injected
in a four-quadrant fashion into the external auditory meatus. The
needle tip is placed just lateral to the bone-cartilage junction, and the
solution is infi ltrated until the skin blanches. (Redrawn from Bluestone
CD, Stool S: Atlas of Pediatric Otolaryngology, 3rd ed. Philadelphia, WB
Saunders, 1996.)
Figure 113-2. The edges of a fresh stellate perforation are everted
from the medial surface of the tympanic membrane. When squamous
epithelium is no longer present in the middle ear, the edges are
reapproximated. (Redrawn from Naumann HH: Head and Neck Surgery,
vol 3: Ear. Stuttgart, Germany, Georg Thieme, 1982.)
Figure 113-3. The edges of the stellate perforation are approxi-
mated and supported with a cigarette paper patch or a Steri-Strip.

Chapter 113
Myringoplasty and Tympanoplasty 1137
Figure 113-4. The edge of the per-
foration is circumferentially freshened
to remove epithelium from the medial
margin and promote local bleeding.
The inset emphasizes that the medial
edge of the perforation must be
removed to eliminate squamous epi-
thelium from the middle ear. (Redrawn
from Naumann HH: Head and Neck
Surgery, vol 3: Ear. Stuttgart, Germany,
Georg Thieme, 1982.)
A
B
Figure 113-5. A, Myringoplasty
of the right tympanic membrane
with a posteroinferior perforation.
The edges of the perforation are
freshened, Gelfoam is placed in the
middle ear, and an areolar or com-
pressed fat graft (stippled area) is
placed through the perforation,
positioned medial to the tympanic
membrane, and supported by the
Gelfoam.
B,
Gelfoam
supports
the graft on the medial surface of
the tympanic membrane.
Gelfoam is placed through the perforation into the
middle ear space. A properly sized tissue graft is placed
through the perforation and sandwiched between the
medial surface of the tympanic membrane and the
Gelfoam (Fig. 113-5). In the absence of signifi cant con-
ductive hearing loss, this technique can be used to
reconstruct such small defects without elevating a tym-
panomeatal fl ap. A small piece of Surgicel placed lateral
to the grafted perforation may be used to further secure
the graft. Gelfoam soaked in antibiotic solution is placed
lateral to the tympanic membrane to fi ll the medial
external canal.
Tympanoplasty
Lateral Grafting Technique
The patient’s head is turned toward the contralateral
side, and the hair is shaved superior and posterior to
the pinna to provide approximately 1 to 2 cm of hairless
skin. After adequate general anesthesia has been
obtained and the operative fi eld has been prepared and
draped, 2% lidocaine with 1:100,000 epinephrine is
injected into the external canal with a dental syringe
and a 27-gauge needle. This is done in at least four
quadrants by placing the needle just at the medial

1138
Section 13
Tympanic Membrane, Middle Ear, and Mastoid
margin of the cartilaginous canal and injecting ap -
proximately 1 mL. Additional infi ltration is placed
at the 12-o’clock position at the incisura down to
the root of the zygoma (Fig. 113-6) (see Video 113-1).
The same anesthetic is also injected into the post-
auricular area a few millimeters posterior to the post-
auricular crease.
Using the operating microscope, incisions are made
in the skin of the external meatus at 12 o’clock and 6
o’clock with a no. 64 Beaver blade. An endaural Lempert
speculum is used to facilitate exposure of these inci-
sions. The 12-o’clock incision begins approximately
1 cm lateral to the lateral process of the malleus and
extends to the tragal incisura. The 6-o’clock incision is
a short incision in the bony canal down to the junction
of the bone and cartilage (see Video 113-2). These two
incisions are then connected vertically along the poste-
rior bony canal wall, about 3 mm medial to the bony-
cartilaginous junction, to create a conchal fl ap (Fig.
113-7). Through this endaural approach the conchal
fl ap dissection is initiated by back-elevating the canal
skin (Fig. 113-8) (see Video 113-3). The 12-o’clock
corner of the fl ap must be completely dissected and
mobilized to facilitate elevation of the skin from the
postauricular approach.
Hatch marks are placed in the postauricular area
over the planned postauricular incision and the skin is
incised a few millimeters posterior to the sulcus. The
skin is initially incised with a no. 15 blade. The incision
can be continued through subcutaneous tissue and the
postauricular muscle with a knife or electrocautery (Fig.
113-9). Subcutaneous dissection is performed along the
posterior aspect of the conchal cartilage to defi ne the
posteriorly based conchal fl ap. The skin of the external
auditory canal is elevated from the postauricular
approach and dissected toward the previously made
endaural incisions (see Video 113-4). A prominent
spine of Henle may be encountered and requires more
vigorous soft tissue dissection. The endaural 12-o’clock
incision is connected with the postauricular incision
by placing a no. 15 blade through the subcutaneous
tissue at the zygomatic root. From the postauricular
approach, the knife is beveled toward the bony canal
wall, and the conchal cartilage fl ap is further defi ned
(Fig. 113-10). The fl ap is then elevated off the posterior
canal wall via the original vertical conchal fl ap incision
made endaurally. When the two incisions are con-
nected, the conchal fl ap is retracted with either a tra-
cheostomy tape and a self-retaining retractor or a
Perkins retractor alone (Fig. 113-11) (see Video 113-5).
Incision into and exposure of the cartilage of the exter-
nal canal may result in pain and possibly chondritis.
This complication is more likely if the 6-o’clock incision
is carried too far laterally or with extension of the post-
Figure 113-6. Local anesthetic is injected in a four-quadrant
fashion into the external auditory meatus and incisura.
Figure 113-7. With a Lempert speculum and a no. 64 Beaver blade,
12- and 6-o’clock incisions are connected with a posterior canal wall
incision, just medial to the conchal cartilage.
Figure 113-8. A large duckbill dissector is used to back-elevate the
conchal fl ap to facilitate subsequent mobilization.

Chapter 113
Myringoplasty and Tympanoplasty 1139
Figure 113-9. An incision with a no. 15 blade is made posterior
to the postauricular sulcus. Electrocautery is used to continue the
incision and maintain hemostasis.
A
B
Figure 113-10. Through the postauricular incision, a knife is used
to dissect the skin from the bony wall of the posterior canal. The blade
is directed toward the bony canal wall to avoid laceration of the skin
of the canal.
Figure 113-11. A, The conchal fl ap has been dissected and inverted
toward the external auditory meatus (dotted lines). A tracheostomy
tape maintains retraction on the soft tissue of the canal. This is then
secured with a self-retaining retractor. A Freer dissector is used to
harvest areolar tissue or temporalis fascia. B, The skin is retracted
with an Army-Navy retractor. Temporalis fascia is removed from the
temporalis muscle.
auricular dissection toward the posterior inferior aspect
of the conchal cartilage.
If the areolar tissue (fool’s fascia) obtained from
the lateral surface of the fascia covering the temporalis
muscle is hearty and well defi ned, this tissue layer is
chosen for grafting. The area over the temporalis
muscle is exposed and a self-retaining retractor is
placed. An Army-Navy retractor may be needed to lift
the temporal skin to facilitate better exposure. A no. 15
Bard-Parker blade is used to superfi cially incise the
areolar tissue layer, and a plane is developed between
this layer and underlying fascia with a Freer dissector
(Fig. 113-11A). Scissors are used to remove a 2 by 2-cm
section. If this proves to be too thin or is deemed to be
inadequate, true temporalis fascia is harvested in a
similar manner (see Fig. 113-11B). Hemostasis may be
necessary for regional vessels. The graft is spread on a
cutting block, cleaned of attached muscle fi bers or
adipose tissue with the side of the knife blade, and
allowed to dry.
The medial aspect of the canal skin is then removed
by circumferentially incising the anterior canal wall at
the bulge (see Video 113-6). The skin remaining in the
canal medial to the incision is then sequentially elevated
toward the fi brous tympanic annulus with duckbill ele-
vators or an oval knife (Fig. 113-12) (see Video 113-7).
Dissection extends medially to remove the canal skin
and epithelium over the tympanic membrane as an
intact sleeve. The easiest area to obtain a clean dissec-
tion plane is at the posterior inferior medial canal and
annulus, which is at the 8-o’clock position in the dem-
onstrated right ear (Fig. 113-12) (see Video 113-8).
Care is taken to elevate all the squamous epithelium off
the remaining tympanic membrane. This dissection is
facilitated superiorly, where the pars fl accida can be
stripped off the lateral process of the malleus in a down-

1140
Section 13
Tympanic Membrane, Middle Ear, and Mastoid
ward fashion with cup forceps, and posteriorly at the
inferior fi brous annulus, where anterior dissection can
be easily performed parallel to the plane of the fi brous
annulus (Fig. 113-13) (see Video 113-9). Often, a small
perforation of the tympanic membrane is made larger
by removing this epithelial layer because of the underly-
ing fi brous layer defect.
A prominent anterior canal wall may obstruct the
view of the anterior annulus. The anterior canal wall
skin is back-elevated in a medial-to-lateral direction to
provide access to the bony anterior canal wall (see
Video 113-10). This area of bone of the anterior canal
may have to be removed with a drill to provide unob-
structed exposure of the anterior canal. This reduces
the incidence of blunting of the angle between the
anterior canal wall and tympanic membrane and facili-
tates postoperative examination and cleaning (see
Video 113-11). If the bony overhang prohibited visual-
ization of the anterior sulcus, the improved exposure
facilitates performance of this step in the procedure
(see Video 113-12). Epithelial remnants may remain in
the anterior and inferior sulcus. Retention of this skin
would result in the development of a middle ear or
intratympanic cholesteatoma. If there is concern that
all the skin was not removed, an angled curette is used
to further dissect the anterior and inferior sulcus just
lateral to the annulus (see Video 113-13).
Tympanoplasty requires inspection of the middle
ear space and reconstruction of the ossicles, when nec-
essary. A sickle knife or curved pick (Rosen needle) is
used to elevate the posterior fi brous annulus while
taking care to preserve the chorda tympani nerve. The
ossicular chain must be completely inspected and pal-
pated (Fig. 113-14). If visualization of the incudostape-
dial joint and stapes footplate is not adequate, bone of
the posterior superior bony canal wall may be removed
with a curette or drill (Fig. 113-15). The status of the
ossicular chain is assessed by palpation. Limited mobil-
ity of the lateral chain (malleus-incus) and fi xation of
the incus-stapes complex will require separation of the
incudostapedial joint. If a cholesteatoma is present in
the middle ear, the incus may need to be removed to
evaluate the integrity of the stapes (see Videos 113-14
and 113-15). Repair of the ossicular chain is reviewed
in Chapter 114.
Middle Ear Disease
Common pathologic processes found in the middle ear
include granulation tissue, hyperplastic mucosa, choles-
teatoma, and tympanosclerosis. Each is managed in a
different way.
Granulation tissue and mucosal hyperplasia require
reconstruction of an aerated middle ear space. Early
assessment of eustachian tube patency directs one’s
decision regarding reconstruction. Failure of tympano-
plasty is likely if irreversible mucosal disease or eusta-
chian tube obliteration is present. Deciding that a
eustachian tube will never function normally is diffi cult
Figure 113-12. With a duckbill elevator, the skin of the bony exter-
nal meatus is elevated in a medial direction until the bony annulus
is encountered. Dissection follows the circumference of the collage-
nous fi brous layer of the tympanic membrane.
Figure 113-13. Most of the epithelial layer of the tympanic mem-
brane has been elevated off the anterior and posterior canal walls and
fi brous tympanic membrane. It remains pedicled along the handle of
the malleus and can be stripped off readily with cup forceps.