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Principles of Temporal Bone and Skull Base Surgery
Built from Haynes-Glasscock-Shambaugh Surgery of the Ear, Seventh Edition
What’s inside
11 sections · 127 slides
Overview
- Scope of these principles
Preoperative assessment
- Two arms of preoperative assessment
- General health review
- Preoperative blood tests and electrocardiogram
- Agents that impair clotting
- GLP-1 receptor agonists and perioperative risk
- Disease-specific evaluation
- Microscopic otoscopy before otologic surgery
- Revision surgery and canal-mastoid fistula
- Preoperative audiometry
- Electronystagmography before vestibular surgery
- Computed tomography before middle ear and mastoid surgery
- Indications for preoperative temporal bone CT
- Further indications for preoperative temporal bone CT
- Neurological examination for skull base surgery
- The multidisciplinary skull base clinic
- Audiologic and neurophysiologic testing
- Absent ABR does not preclude hearing preservation
- Electronystagmography and VEMP in skull base workup
- Magnetic resonance imaging of skull base lesions
- Diffusion-weighted imaging for epidermoid cysts
- Vascular imaging and angiography
- Timing of preoperative embolisation
- Octreotide scanning and skull base CT
- Biochemical workup and alpha blockade in paraganglioma
Preoperative patient preparation
- Content of preoperative patient education
- Expected outcome versus complication
- Choice of anaesthetic
- Functional criteria for hospital discharge
- Risks of prolonged hospitalisation
- Discharge instructions for patient and family
- Activity, Valsalva and follow-up imaging
Medical preparation
- Surgeon and anaesthesiologist discussion
- Intraoperative fluid management in skull base surgery
- Consequences of intraoperative overhydration
- Anxiolysis and antiemetic prophylaxis
- Antibiotic prophylaxis in otologic surgery
- Prophylaxis in actively draining ears
- Glycaemic control and surgical site infection
- Brain protection before neurotologic procedures
- Antibiotic prophylaxis for skull base procedures
The operating room
- Transition to the operating room
- Patient positioning and airway security
- Head positioning for trans-temporal procedures
- Preparation immediately before incision
- Position of the scrub and video monitor
- Who operates the foot pedals
- Operating room layout for a left-sided lesion
- Operating room layout for a right-sided lesion
- Layout for a right-handed surgeon seated at the head
- Layout for a left-handed surgeon seated at the head
- Value of a consistent operative team
Surgical site preparation
- Hair removal and skin cleansing
- Choice of preparation solution
- Draping and irrigation runoff
Surgical technique
- Elements of sound operative technique
- Haemostasis demands in microsurgery
- Injection sites for transcanal procedures
- Tragal injection
- Injection at the incisura
- Injection of the ear canal floor
- Posterior ear canal injection
- Deep canal injections
- Greater auricular nerve block
- Postauricular tissue infiltration
- Volumes and adjuncts for postauricular infiltration
- Delivery technique and needle choice
- Injection under general anaesthesia
- Monopolar and bipolar electrocautery
- Topical epinephrine in the middle ear
- Control of bone bleeding
- Mechanism of diamond bur haemostasis
- Immediate response to sigmoid sinus injury
- Gelfoam patch repair of the sigmoid sinus
- Reverse Trendelenburg and its caution
- Options when the patch fails
- Extraluminal and intraluminal packing of the sinus
Exposure
- The principle of adequate exposure
- Hazards of a narrow deep corridor
- Planning incisions and vascular control
- Requirements of the operating microscope
- Microscope preparation and surgeon ergonomics
- Advantages of drilling under magnification
- Anatomic pointers to the facial nerve
- Eggshell technique and facial nerve monitoring
- The internal carotid artery in skull base surgery
Bone dissection
- Drills as bone dissection tools
- Bur condition and the risk of dull burs
- Characteristic errors of the novice
- The CNC milling model of bone dissection
- Reading wet bone
- Pressure, hand support and bur selection
- Saucerisation and bone dust
- Sensory feedback while drilling
- Cutting and diamond burs
- Wound closure and cerebrospinal fluid leak
- Recognising the limit of expertise
Postoperative care
- Post-anaesthesia care unit
- Disposition after otologic surgery
- Care after craniotomy
- Mobilisation after neurotologic surgery
- Lower cranial nerve deficits and swallowing
- Airway and nutritional measures
- Postoperative steroids and antibiotics
- Re-expansion oedema after brainstem decompression
- Corneal protection in facial nerve weakness
- The first postoperative visit
- Balance rehabilitation and return to work
- Structure of later follow-up
Summary
- Principles that carry across every case
- Recurring safety rules
- References
- References (continued)
- References (continued)
- References (continued)
- Haynes-Glasscock-Shambaugh Surgery of the Ear, Seventh Edition
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