Surgery Course Conducted in Islamabad
October 22, 2024Surgery Course Conducted in Islamabad
October 22, 2024Pediatric Tympanomastoidectomy and Meatoplasty for Cholesteatoma: In this surgical video, Dr. Akbar Abbas provides a detailed walkthrough of a tympanomastoidectomy and meatoplasty performed on a 4-year-old child diagnosed with cholesteatoma.
The procedure involves meticulous dissection, drilling, and reconstruction techniques to address the aggressive nature of the cholesteatoma, while ensuring the protection of delicate structures like the facial nerve. This step-by-step guide covers everything from initial incisions to cavity reconstruction, providing valuable insights into the complexity of pediatric ear surgery.
Step-by-Step Surgical Narration for Pediatric Tympanomastoidectomy and Meatoplasty:
Patient Presentation:
A 4-year-old child presented with severe ear pain. Upon examination, cholesteatoma was identified in the mesotympanum, extending into the retrotympanum. Surgery was planned to address this extensive condition, and a postaural incision was made to begin the procedure.
Raising the Tympanomeatal Flap:
The tympanomeatal flap was elevated as part of the inside-out technique. This technique involves removing the outer scutum and attic until the dura is clearly identified.
Dura Identification:
The key aspect of the inside-out technique is the identification of the dura. Dr. Abbas emphasizes the importance of achieving a proper view of the dura, which acts as a guide throughout the procedure. Once identified, drilling was performed along the dura to reach the antrum.
Drilling the Mastoid Cavity:
A cutting burr was used to drill out the scutum, exposing the antrum and removing the cholesteatoma from the surrounding structures. In this case, the cholesteatoma was aggressive and involved extensive areas including the mastoid tip cells, sigmoid sinus, and sinodural angle.
Facial Recess and Sigmoid Sinus:
The cholesteatoma was adherent to the facial recess and the sinus tympani, extending deep into the sinus. Special care was taken to avoid injury to the facial nerve, which is often dehiscent in such cases.
Dissection of Cholesteatoma:
Dr. Abbas carefully dissected the cholesteatoma from critical areas, including the tensor tympani muscle and the eustachian tube opening. The cholesteatoma matrix was removed from the facial recess, sinus tympani, and around the stapes footplate.
Meatoplasty:
Meatoplasty was performed to widen the ear canal and ensure proper drainage of the mastoid cavity. Dr. Abbas described creating incisions at the 6 o’clock and 12 o’clock positions to remove cartilage and prevent future stenosis.
Canal Wall Down Technique:
The entire mastoid cavity was drilled out, performing a canal wall down procedure to eliminate any residual disease and open up the retrotympanum.
Handling the Facial Nerve:
The facial nerve was preserved during the removal of the cholesteatoma, especially in the second genu and horizontal segments. A diamond burr was used to gently clear any disease close to the nerve while avoiding trauma.
Reconstruction with Cartilage Graft:
Dr. Abbas reconstructed the area with a cartilage graft fashioned into an inverted pyramid. This cartilage serves as a scaffold for future sound conduction, particularly since the stapes suprastructure was absent.
Temporalis Fascia Graft:
A temporalis fascia graft was placed in a V-shape, with one limb covering the new tympanic membrane and the other providing coverage over the mastoid cavity. Gel foam was used to secure the graft in place.
Final Cavity Inspection:
Once the cholesteatoma was entirely removed, the cavity was irrigated with saline to clear any residual debris. The mastoid cavity was lined with temporalis fascia, and antibiotic-soaked gel foam was placed to ensure proper healing.
Postoperative Management:
A bipedal pack was placed and would remain in situ for one month, after which it would be removed in the clinic.
This thorough and precise procedure by Dr. Akbar Abbas demonstrates the expertise needed to manage complex cholesteatoma cases in pediatric patients. Each step emphasizes both the surgical challenges and the critical importance of protecting delicate structures like the facial nerve while ensuring full cholesteatoma removal.
This guide provides a valuable resource for students, residents, and practitioners looking to understand the intricacies of pediatric tympanomastoidectomy and meatoplasty.
This educational video allows students and patients to make informed decisions about their own and others’ health. Dr Akbar Abbas is a leading figure in ENT surgery within Pakistan, offering hope and expertise to countless patients facing similar challenges. He specializes in otolaryngology, cochlear implants, and ear surgery and is one of the few experts on pituitary and head and neck cancer surgery in Pakistan. Presently serving at Aga Khan University and Hospital.
