A complete case by Dr. José Carlos Casqueiro
In the SurgSchool app, we pride ourselves on providing high-quality surgical training through advanced educational resources. In this article we highlight an exceptional video of our surgical training app, where the Dr. Casqueiro performs complex endoscopic surgery for the treatment of grade 4 tympanic atelectasis with cholesteatoma. We detail each phase of the surgery, providing valuable guidance for otolaryngologists looking to hone their skills.
Case Description
The patient is a 37-year-old man who has experienced recurrent otorrhea in the right ear. During examination, a grade 4 complete tympanic membrane atelectasis was identified, accompanied by a retention cholesteatoma and a visible granuloma posteriorly. Medialization of the malleus handle was also noted, further complicating the case.
Ear Canal Preparation
The surgery begins with the preparation of the ear canal. Because men tend to have more hair in the canal, Dr. Casqueiro performs a careful grooming of the auditory meatus, trimming the hair to avoid wounds that may bleed during the operation.
«It is essential to trim the hair in the ear canal carefully to avoid wounds that could bleed during the operation», highlights Dr. Casqueiro.
Hydrodissection and Clearing of the Affected Area
Once the duct is prepared, hydrodissection is carried out to remove the problem areas from the tympanic membrane, facilitating a safer and more effective dissection of the ossicular chain and the tympanic membrane.
«Hydrodissection helps to detach the tympanic membrane and facilitates a more controlled dissection»explains Dr. Casqueiro.
During this phase, a perforation is identified in the granuloma area, which increases the complexity of the case. Dr. Casqueiro uses a duckbill and performs strategic infiltrations to stabilize the area and minimize complications.
Flap Elevation and Bleeding Control
The surgery progresses with meticulous elevation of a flap on the tympanic membrane. This procedure is delicate and requires precision to avoid damaging critical structures. Dr. Casqueiro uses an aspirator and gauze with adrenaline to control the bleeding.
«It is essential to control bleeding during flap elevation to maintain optimal visibility and ensure surgical precision»says Dr. Casqueiro.
Dissecting the Cholesteatoma
The cholesteatoma is dissected very carefully to avoid leaving skin remnants that could become an iatrogenic cholesteatoma. Dr. Casqueiro emphasizes the importance of thorough dissection to ensure that no inflammatory tissue or mucosa remains that could cause problems in the future.
"The key is to dissect little by little, making sure not to leave anything that could cause an iatrogenic cholesteatoma", points out Dr. Casqueiro.
Cleaning and Disinfection of the Affected Area
The next step is careful cleaning of the affected area. Using a dissector, Dr. Casqueiro exposes and removes inflamed areas, ensuring the integrity of key structures such as the round window and stapes to prevent any damage that could result in permanent hearing loss.
«Working slowly and carefully is crucial to thoroughly clean the ear cells and remove the inflammatory mucosa», emphasizes Dr. Casqueiro.
Identification of Anatomical Structures
During surgery, it is vital to identify and preserve important anatomical structures such as the subcochlear canaliculus, fustis, and round window. These structures guide the process of cleaning and removing inflammatory mucosa without damaging the inner ear.
Use of Specialized Tools
Various tools such as spoons, aspirators and dissectors are used to ensure complete cleaning. Thicker optical tools allow for better viewing, although they may limit maneuverability in tight spaces. Choosing the right tool is vital to the success of the operation.
Eardrum Reconstruction
The final phase of surgery involves reconstruction of the eardrum with cartilage, usually obtained from the patient's tragus. The cartilage is meticulously dissected and prepared to ensure it fits properly and provides the structure necessary to prevent future tympanic retractions.
Postoperative Considerations
Dr. Casqueiro highlights the importance of minimizing manipulation to reduce postoperative dizziness, a common but manageable complication. Furthermore, he emphasizes that a thorough cleaning is not always necessary if it is not a cholesteatoma, since the residual mucosa under the tympanic retraction can be adequately managed.
Resources and Education
Professionals are recommended to consult specialized texts such as «Endoscopic Ear Surgery» de Daniele Marchioni and Livio Presutti for a detailed learning of the anatomy of the retrotympanum. This resource is valuable in better understanding the complexities of endoscopic ear surgery.
