(Ugo Fisch, Thomas Linder) Temporal Bone Dissectio PDF

In collaboralion wilh
Deparlment ot ENT, Lucerne Cantonal Hospital, Switzerland

TEMPORAL BONE DISSECTION
- The ZURICH Guidelines -
Prof. Ugo FISCH, M.D.

ENT Center, Hirslanden Hospital, Zurich, Switzerland
In collaboration with
Assoc. Prof. Thomas LINDER, M .D.
Department of ENT, Lucerne Cantonal Hospital, Switzerland
89 Illustrations by
Katja Dalkowski, M.D.
Buckenhof, Germany
This booklet is based on teaching material distributed at

the yearly held Temporal Bone Dissection Courses organized
by the Fisch International Microsurgery Foundation
at the Anatomy Department of the University of Zu rich, Switzerland
Chairman: Prof. Peter Groscurth, M.D.
We are grateful to the follow ing persons,

who have helped in our courses for more than
15 years and contributed in developing the principles
exposed in this booklet:
Prof. John May, M.D.

Wake Forest University, Winston Salem NC, USA
Prof. Rodrigo Posada, M.D.

University of Pereira
Pereira, Colombia
FISCH INTERNATIONAL MICROSURGERY FOUNDATION

4 Temporal Bone Dissection - The Zurich Guidelines
Illustrations by: Temporal Bone Dissection - The Zurich Guidelines

Katja Dalkowski, M.D. Prof. Ugo FISCH, M.D.
Grasweg 42 ENT Center, Hirslanden Hospital, Zurich. Switzerland
0-91054 Buckenhof, Germany In col laboration with
Email: kdalkowski@online.de Assoc. Prof. Thomas LINDER, M.D.
Department of ENT, Lucerne Cantonal Hospital. Switzerland
Contact:
Fisch International Microsurgery Foundat ion
Forchstr. 26. CH-8703 Erlenbach
Switzerland
Phone: +41 (0) 1 9106828
Fax: +41 (0)1 9106126
Email: fisch@orl-zentrum.com
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Temporal Bone Dissection - The Zurich Guidelines 5
Table of Contents
A.1 Introduction .................. .. . . ........... .. . . . . .... . .. . ... ........ 6
A.2 General Preparation ............. . . . . . ... .. . . . .. ... . .... . . . ....... . .... 6
A.3 Specific Surgical Techniques ...... . .. . . . . .. . . . .. . . .. . . . ...... . . . . .. ... • 7
B Closed-Cavity Technique .... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

B.1 Tympano-Antrotomy
(Meatoplasty, Canalplasty, Myringoplasty, Antrotomy,
Epitympanotomy, Osslculoplasty, Mastoid Drainage) .... . . .... ........ 7
B.1.1 Meatoplasty . . ..... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
B.1.2 Canalplasty ......................................... . . . . . . . . . . . . g
B 1.3 Myringoplasty ............ . . ...... ................ . . . .. . . .. ...... 13
B.1.4 Antrotomy ................. . . .... ................ . . .... ......... 15
B .1.5 Epitympanotomy .............. . . .. .................. . . .. ......... 15
B.1.6 Transmastoid Drainage of the Antrum ............................... 16
B .2 Tympano-Mastoidec t omy
(Meatoplasty, Canalplasty, Epitympanec tomy. Mastoidectomy,
Posterior Tympanotomy, Ossiculoplasty, Myringoplasty, Mastoid Drainage)
B.2.1 Mastoidectomy ............................................. 17
B.2.2 Posterior Tympanotomy ...... ................ ...... .......... 17
B.2.3 Epitympanectomy ........... ............ ...... ...... . . . . .. . . 18
B.3 Myringoplasty and Ossic uloplasty in Closed Cavities
B.3.1 Myringoplasty ......... . .......................... . . .. . .•. .. 19
B.3.2 Ossiculoplasty (Incus-Interposition) .................. . .. ...... . 20
C Stapedotomy
C.l Incus-Stapedotomy .............................................. 22
C.2 Malleo-Stapedotomy ............ ... ................... ... ......... 28
o Open Cavity Techniques (Mastoido-Epitympanectomy, Open MET)

D.1 Mastoidectomy ........ ........ ........................ .... . .. ... 32
D.2 Epitympanotomy ................................................ . 34
0 .3 Completion of Mastoido-Epitympanectomy .......................... 34
E Tympanoplasty (Myringoplasty and Ossiculoplasty) in Open Cavities .........• 35

E.l Type III Tympanoplasty ....... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • 35
E.2 Total Reconstruction of the Ossicular Chain .......................... 36
E.2. l Fisch Titanium Total Prosthesis .......................... . . . . . . . . . . . 36
E.2.2 Titanium Neo- Malleus . . . . . . . . . . . . . . . . . . . . . . . . • . . . . • . . . . • . . . . . . . . . . 41
F Additional Temporal Bone Dissections

F.l Subtotal Petrosectomy .... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
F.l.1 Subtotal Petrosectomy with Preservation of the Otic Capsule ........ ... 42
F.l.2 Subtotal Petrosectomy with Removal of the Otic Capsule .... . . . . . . . . . . . 43
G Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
H Prostheses and Instruments
H.l FISCH Titanium Middle Ear Prostheses. . . . . . . . . . . . . • . . . . . . . . . . • . . . • . . 45

H.2 FISCH Special Instruments for Tympanoplasty,
Mastoidectomy and Stapedotomy . . . . . . . . . . . . . . . . . • . . . . • . . . . . . . . . . . . 45
-
A.1 Introduction A.2 General Preparation

The series of surgical techniques described in this article The temporal bone should be placed in the normal operat -
relates to procedures that can be practiced in a course ing position, with the posterior aspect toward the surgeon
using two temporal bones. The first bone is used to and the temporomandibular joint away from the surgeon.
demonstrate the closed-cavity tympana-mastoidectomy
with related myringoplasty and ossiculoplasty (incus inter- Remove excess bone from the temporal squama using a
poSition), The second bone is used to demonstrate stapes cutting burr to ensure that the remaining temporal bone fits
surgery ~ncus-stapedotomy and malleo-stapedolomy) and Within the holder, permitting complete rotation in the
open-cavity mastoido-epitympanectomy. anlero-posterior plane.
The surgical steps described in these guidelines require Initially, the external ear is left attached to the temporal
special instrumentation. The most important instruments bone to enable the meatoplasty technique to be performed
are mentioned in the text, highlighted in italics. For more Within closed cavities. Following meatoplasty (or when the
details on Prostheses and Instrumentation see Section H. pinna is not available), the external canal is transected
2 em lateral to the bone-cartilaginous junction. All excess
More information concerning the descnbed surgical proce- soft tissue that is not used during the dissection is
dures is given in Section G (Suggested Reading). removed from the bone.
Identify the following anatomical landmarks (Fig. 1):

CD Temporal line ® Tympanomastoid suture
® Spine of Henle ® Tympanosquamous suture
@ Mastoid tiP ® Petrotympanic fissure
Zygomatic process
, I
ArtICular tube«:le
Petrotympanic fissure
Styloid pmcess
TympaniC booe
Mastoid process
- - @Mastold tip
CD Temporal line
® Spine 01 Henle
@ Tympar.ornastold suture
M. dlgaslncus
M. sternocleidomastoideus M. longus capi tis
1 M. spleniUS capitis
A.3 Specific Surgical Techniques
B Closed-Cavity Technique
B.1 Tympano-Antrotomy
The steps of this operation are: , '..,..

'""'"',"
Meatoplasty, Ganalplasty, Ossiculoplasty, Myringoplasty, .': .'
Antrotomy, Epitympanotomy and Mastoid Dramage. •
2,
B.1.1 Meatoplasty
General Considerations
Meatoplasty is a necessary step in addition to canalplasty

when the cartilaginous portion of the external auditory
canal (EAC) is too narrow in relation to its osseous portion
(Fig. 2 a, C). Lateral stenosis of the EAC is commonly relat-
ed to congenital anomalies, minor malformations, exosto-
sis and postsurgical scarring. II may lead to hearing impair- c
ment, excessive accumulation of cerumen , chronic otitis
.
...'
exlema. difficulties in clinical examination and insufficient
self-cleansing properties of the external ear following :,,'.
.- '.
•
canalplasty. '" ,
•'.
The principle of meatoplasty is to remove the obstruction
crea ted by excessive conchal cartilage and bone (Figs. 2 a,
•
b; A-B). The operation is performed with a microscope.
2.
Skin Incision
The first superior skin incision begins at the 12 o'clock
position between the tragus and helix, as is the case of an
endaural approach (Fig. 3, A-B-C). and is continued down
to the level of the superior edge of the bony external audi -
tory canal.
The second incision is made at 6 o 'clock and continues
through the ring of cartilage forming the inferior edge of the
EAC (Fig. 3, D-E).
A third, medial skin incision connects both previous in-
cisions horizontally along the posterior edge of the EAC
(Fig. 3, C-O).
3
Elevation of the laterally Based Skin Flap

The laterally based skin flap is elevated using tympanoplasty
scissors. Care must be taken to keep the skin intact, parti-
cularly when separating it fro m the thin but strong attach- A
ment to the conchal cartilage (Fig. 4).
Endaural Retractor
Excess of bone behind

Bony external canal external auditOf)' canal
Conchal
cartilage
5. 5. Edge of excised
Skin flap conchal cartilage
Exposure and Excision of Conchal Cartilage

Excess conchal cartilage is exposed (Fig . 5 a) and excised
(Fig. 5 b). and the soft tissues situated between the
excised cartilage and the underlying bone are also
removed.
B
Enlargement of the Bony EAC
The posterior wall of t he bony EAC is enlarged using a dia-
mond burr (Fig. 6).
Wound Closure
• Belore closing the wound, a relieving Incision is made
through the inferior part of the laterally based meatal skin
flap (Fig . 7, F) to allow superior rotation of its upper part
(Fig. 8, C, 0). In this way, the enlarged superior external
auditory meatus is completely covered with skin. which is
• kept in position with 4-0 Et hibond sutures (Fig. 9). The

inferior enlarged portion of the EAC is left open and w ill
heal by secondary intention within 2-3 weeks.
E
NOTE: A meatoplasty can be performed on the tempo-
ral bone only if the pinna has been preserved. Pertorming
a meatoplasty will not allow the surgeon to carry out the
F first steps of the retroauricular approach described under
B 1.2.
Relieving
inciSion
• 9
Aetroauricular
'0
'" 11b
B.1.2 Canalplasty
The goal of any tympanomastoid surgical procedure
should be the circumferenttal enlargement of the bony
extemal canal to visualize the entire ring of the tympanic
annulus using one position of the microscope (Fig. 10).
Periosteal Flap
The outline of the relroauricular periosteal flap is formed
with a knife (No. 15 blade) and should be approximately the
size of the index finger (Fig. 11 , A). The periosteal flap
is elevated from the bone with a mastoid raspatory 12
(Fig. 11, B).
Exposure of the EAC

The posterior limb of the canal incision (Fig. 12, A-B)
is pertormed with a No. 15 blade, maintaining a level below
the entrance of the bony external canal. The EAC is then
opened and the canal incision is extended anteriorly
(Fig. 13, B-C) 10 the 2 o 'clock position (right side). The soft
tissues are moved away from the bone using a Key raspa-
tory.
13
10 Temporal Bone Dissecr on - The Zurich Guidelines
,,
,
14.
•
I
7em
15. 150
Meatal Skin Flap

"•
Visualization of the entire tympanic membrane using one
position of the microscope is made possible by forming a
large meatal skin flap that is carefully dissected oul of the
canal with its inferiorly based pedicle left in place. In the
clinical setting, the advantage of this type of flap is that its
blood supply is maintained through its pedicle.
15c
Incisions for the Meatal Skin Flap

The meatal flap is incised using a No. 11 blade mounted in Elevation of the Meatal Skin Flap
a special rounded scalpel handle. The blade is guided
The skin is elevated from t he bone using a Fisch microras-
along the lines shown in Fig s. 14 a (right ear) and 14 b (left
patory in the right hand and a microsuction tube in the left
ear).
hand (Figs. 15 a , b). The microsuction tube should have a
Two Incisions are made: the first spirally ascending from length of 7 cm to permit the surgeon's left hand to rest
medial to lateral (Figs. 14a, b; D-C), and the second run- comfortably on the head of the patient (Fig . 15 b).
ning medially and circumferentially (D-E).
The tiP of the microsuction tube holds the skin away. The
The spiral Incision starts 2 mm lateral to the annulus at amount of negative pressure of the microsuction tube is
7 o'clock (right temporal bone) and swings up laterally controlled with the left index finger (Fig. 15 b).
along the anterior canal wall to meet the previously cut
external canal skin at 2 o'dock (C). Be aware that skin inci- The tip of the microraspatory shoutd always remain in con-
sions in the temporal bone do not bleed and are at times tact with bone. Small movements separate the meatal skin
difficult to visualize. Therefore, it is highly advisable to keep from the bony EAC in the vertical and horizontal planes
in mind the t rack previously used by the tip of the knife and (Fig. 15 c). A small st rip of gauze soaked in saline soiution
to make the incision in a step-by-step fashion. The corre- protects t he skin during separation from t he bone with the
sponding skin incisions for the left ear are shown in Fig. 14 b. Fisch microraspatory.
Temporal Bone Dissection - The Zurich Guidelines
"
..----'.
,,
D
,.. '.b
c
• D
16< 16d
Skin covering
Circumferential Skin Incision lateral portion
Following elevation of the lateral part of t he meatal skin ~_c of tympanic bone
flap, the circumferential incision of the meatal skin is creat -
ed, beginning and ending (Fig. 16 a , D-E) 2 mm lateral to
the tympanic annulus at 7 o'clock (right ear) or at 5 o'clock
(left ear), at the starting point of the spiral incision (see also
Figs. 14 a, b). The anterior limb of the incision is carried out
using tympanoplasty microscissolS (modified Bellucci scis-
sors) along the edge of the antero-inferior bony overhang
of the EAG. The posterior limb of the incision is initiated by
cutting through the posterior surface of the meatal skin
flap with a No. 11 blade mounted to a rounded scalpel Meatal
knife (Fig. 16 b). The incision is then continued along the skm nap
superior canal wall connecting the anterior and posterior
Medial
DE
limb with straight mlcrotympanoplasty scissolS (Fig. 16 c).
Fig. 16 d shows the completed meatal skin flap (see also skin
Fig. 14 a). ofEAC
Elevation of Meatal Skin Flap from the Tympanic Bone

Gare is taken at this stage to expose the complete tympan-
ic bone, including its lateral sur1ace. This requires an exten-
sion of the base of the meatal skin flap from the tympano-
mastoid sut ure in t he antero-superior direction to include
the posterior and lateral sur1ace of the tympanic bone
(Fig. 17, C-D). 17
TymparlO- Exposed lateral

squamous surface 01
suture tympaniC bone
"\
••,
,,,
Meatal
I ff- skin flap
Medial
skm of
EAC
Key raspatory
Tympano-
mastoid suture
...
-_ .. ,/
,-- ,-- -- --
'
",
18
19
Separation of the skin covering the posterior surface of the

tympanic bone is accomplished uSing a Key raspatory. The
tip of the raspatory is moved along the lateral portion of the
anterior bony canal wall, and then gently rotated anteriorly
to completely uncover the superior edge of the tympanic
bone (Fig. 18). In this way. the lateral surface of the
tympanic bone Is completely exposed from the tympano-
mastoid to the tympana-squamous suture. This exposure
is a prerequisite to performing an adequate circumferential
canalplasty (Fig . 19).
20a
Canalplasty
Most commonly, viewing is limited to the antero-inferior
portion of the drum owing to an excess of tympanic bone.
The correct enlargement of the EAC is obtained by drilling
away the overhanging bone with sharp and diamond burrs
(Figs. 20 a-c).
In a narrow EAC, It is difficult to identify the antero-inferior
tympanic annulus, which may be completely covered by
bone. In this situation, a groove (trough) is made in the
bony infenor canal wall at 6 o'clock (Fig. 21 ) until the white
line of the tympanic annulus becomes clearly visible. This
20b techmque of the mfenor trough was developed to avoid
injuring the facial nerve, jugular bulb or internal carotid
artery because these structures are out of reach if the
drilling is performed along the inferior EAC wall and
remains lateral to the tympaniC annulus (Fig . 21 ).
After identification, the tympanic annulus is progressively
exposed as far as the anterior and posterior tympanic
spine. When all bone overhangs are eliminated, the com-
plete drum can be viewed without having to readjust the
position of the microscope (Fig . 22 a and b).
After correct canalplasty, it may become necessary to
apply relieving incisions on the medial meatal skin to return
it to a proper position (Fig. 22 b).
20c
Tympanic
annulus
TympaniC
annulus
21 22,
B.1.3 Myringoplasty
Middle Ear Inspection and Preparation

for Grafting
Freshening the Perforation Margins

The margin of the large central perforation is refreshed
uSing ultra fine biOPSY forceps (Fig . 23 a).
This is done before elevation of the tympanomeatal flap to
provide sufficient stability of the drum.
22"
Elevation of the Tympanomeatal Flap
A posterosuperior tympanomeataJ flap is elevated
with the microraspatory starting from the pos-
terior tympanic spine to expose the malleus
handle, the long process of the incus,
and the stapes (Fig . 23 b). The chorda r
tympani is preserved and separated
from the undersurface of the drum
using a Fisch Tenotom. The inferior
annulus is separated from his bony
sulcus using a microdissector (Fig . 23 c).
Elevation of the tympanomeatal flap is
continued to the 4 o'clock position (on
the right side versus 8 o'clock in a left
bone) to gain sufficient anterior access for
fixation of the underlay graft. Note that the
lerms "under- and overlay ~ are used in
relation to the bony tympanic sulcus and 23b
not in reference to the tympanic mem-
brane (see also B.3.1. Myringoplasty,
page 19) Never elevate the annulus of
the nght anterior tympana-meatal angle
between 2 and 4 o'clock (or between 8
and 10 o'clock, respectIVely, on the
/eft side). Elevation of the anterior
annulus leads to blunting and impairs
the functional results of tympanoplasty.
••
••
Division of the Tympanomeatal Flap ••
(Swinging-Door Technique)
The elevated Iympanomeatal flap is divided
posteriorly using tympanoplasty microscissors
to form two swinging-door flaps (Fig 23 d).
23, 23d
Inspection of the Ossicular Chain

Enlarge the postero-superior canal wall with a small curette
10 expose the anterior malleal process and ligament, the
InclJdo-malieal toint, and the complete stapes (Figs. 24 a, b).
Check the integrity of the ossicular chain and verify its
mObility. Disarticulate the incudo-stapediaJ joint using a
Joint knife (Fig . 24 b) to prevent cochlear damage while
, manipulating the ossicles (particularly the malleus handle).
Epithelial debris is cleaned from the malleus tip using a
1.5 mm 45 0 hook while the malleus handle is lateralized
with a second hook (Fig. 24c),
Adjun ctive Anterior Fixation of the Underlay Graft
(Subtotal Perforation)
In the presence 01 subtotal or anterior perforat ions, the
tympanic annulus is separated from t he sulcus betw een 1
24. and 2 o'clock (right ear) (Fig. 25 a). The antero-superior
portion of the temporalis fascia will be kep t in position
t hrough t his gap. This eliminates the need to introduce
Gelfoam 1M into the protympanum to fix the fascia against
the lateral wall of the latter.
Anterior Drilling of the New Tympanic Sulcus
An,_ mallea! process
A new tympaniC sulcus is drilled with a small diamond burr
matleal ligament along the medial bony edge of the EAC between 4 and
2 o'clock (Fig. 25 b). This ledge of bone is used for later
positioning of the fascia as seen in the insert of Fig. 25 b .
Anterior
tympaniC
spine
Posterior
tympanic
spine
24"
.....--
••••
I
,,,
,,,
,,
,
.,
'.,
\ ,,
,,
,,
\."",.
25b
'.~'" ••• •.. '.': : ...
24< ••••••••••
•
Fixation Points for Underlay Grafting

In subtotal and large antero-inferlor perforations, the
underlay fascial graft will be supported by the following
points: •
•
•
CD On the ledge of the new anlero-inferior tympanic sUl- •

cus.
<I> Under the malleus handle. \
<Il On the posterior tympanic sulcus and chorda tympani.
® On the gap between the antero-superior tympanic ••
annulus and sulcus. • •••
,
• •••
\ •
,•
,,
•
B.1.4 Antrotomy 26
The anlrotomy is carried out when the function of the

eustachian tube is questionable or when the middle ear
mucosa is abnormal. The position of the antrum is deter-
mined by the intersection of the temporal line and a line
parallel to the posterior canal wall (Fig. 27),
The middle cranial fossa dura and the sigmoid sinus are
identified by drilling away the bone until they become visi-
ble through the last shell of covering bone (skele tonization) .
The antrum is found by removing the bone along the skele-
.I-
. ... ••••
tonized middle cranial fossa dura. No bone should
be removed over the entrance of the EAC. The antrum is
opened until the lateral semicircular canal is exposed
(Fig. 28).
B.1 .5 Epitympanotomy
27
Water Test for Epitympanic Patency

Irrigate the antrum wit h water dispensed from a rubber malleus head have been identified and exposed (epitympa-
bulb and ensure that the Ringer's solution flows freely into notomy). Obstructing scars or thickened mucosa sur-
the middle ear and out of the ear canal. If t his is not the rounding the ossicles are removed to achieve adequate
case. drill away the bone along the skeletonized middle patency of the aditus ad antrum (epitympanectomy) (see
cranial fossa in an anterior direction until the incus and Fig. 64, page 32).
.~ .
28 29
300 30b
Transmastold drain
8 .1.6 Transmastoid Drainage

of the Antrum
After exposmg the antrum, a groove is drilled posteriorty

Retroauncular along the sinodural angle to guide the transmastoid drain
, skin incision (Kala-Drain) (Fig. 30 a). The polyethylene drainage tube,
having an outer diameter of 5 mm, has been bent by plac-
, ing it over a curved metal stylus and healing it in an oven at
a temperature of BOoe. The angle of the bent lube is 110°.
The Iransmastoid drain is placed with its bend in the
antrum through a separate rel roauricular slab incision
using a curved clamp. (Figs. 30b, c).
Stab incision
for drain
B,2 Tympana-Mastoidectomy
30c
The sleps required for a closed Mastoido-Epitympanec-

(omy with Tympanoplasty (MEl) are:
Meatoplasty, Ganalplasty. Epltympanectomy, Mastoidec-

tomy, Posterior Tympanotomy. Osslculoplasty. Myringo-
plasty, and Mastoid Dramage.
Some of these surgical steps are the same as for retroau-

ricular tympano-antrotomy and have been discussed in the
preceeding chapter (see page 7).
B.2.1 Mastoidectomy
Ide ntification of the Fac ial Nerve (Fig. 31)
• Enlarge the antrotomy superiorly by skeletonizing the

'"
middle fossa dura. Perform the epltympanotomy to
expose the incus and malleus head. Identify the tym-
panic segment of the facial nerve inferior to the later-
al semicircular canal <D.
• Skeletonize the sigmoid sinus and expose the sin'
odural angle. Do not work in a hole or underneath
bonyedges l
• Expose the lateral surface of the digastric muscle
along the mastoid tip. Follow the superior edge and
lateral surface of the digaster muscle anteriorly to
identify the stylomastoid periosteal fibers (curving
antero-superior). and skeletonize the stylomastoid
foramen, .
• Expose the posterior semicircular canal. Remember
that the pyramidal segment of the facial nerve is Situ-
ated 2 mm antero-Iateral to the infenor edge of the
posterior semicircular canal <D.
• Use the lateral and posterior semicircular canals and
the stylomastoid foramen to estimate the course of
the facial nerve. Skeletonize the mastoid segment of
the facial nerve in a retrograde fashion USing large
diamond burrs to drill over a wide field on the com-
pact bone covering the lateral surlace of the nerve.
B.2.2 Posterior Tympanotomy
32
The space between the pyramidal segment of the facial
nerve, the chorda tympani, the buttress over the lateral
process of the incus, and the posterior canal wall is called
the facial recess (Fig. 32). There is great variability in size
and pneumatization of this area. The bone between the
pyramidal segment and the chorda tympani is drilled away
(Fig. 33) while keeping an eye on the skeletonized mastoid
and pyramidal segments of the facial nerve. The resulting
opening to the middle ear is the posterior tympanotomy.
Avoid exposing the facial nerve (leave a small shelf of bone
to cover and protect the nerve) or touching the Incus with
the burr. and do not injure the chorda tympani and the tym·
panic annulus. Do not make the pestenor canal wall too
thin to avoid delayed atrophy (Fig. 33).
33
With the facial nef'Ve in view, the facial recess can be

enlarged as much as possible. If the mastoid is narrow, the
bony buttress behind the posterior ligament of the incus is
removed to gain sufficient space. A diamond burr is used to
lower the bone covenng the lateral semicircular canal, and
the pyramidal and distal tympanic segments of the fallopian
canal. This will also expose the chorda tympani (Fig. 34),
Through the posterior tympanotomy and epitympanotomy
the following middle ear structures should be identifiable:
• stapes and stapedial tendon

• tympanic segment of the facial nerve
• round window
• incus with short and long process
• mal leus head, cochleariform process and tensor
34 tympani tendon
• eustachian tube orifice (occasionally, Fig. 45)
8 .2.3 Epitympanectomy
The incudo-stapeclial joint is separated , and the incus is

• mobilized with a 1.5 mm. 45° hook (Fig. 35a) then removed
by lateral rotation , preserving the chorda tympani
(Fig. 35 b). The long process of the incus may be cut with a
1.5 mm
45' Hook malleus nipper when the integrity of the chorda is at risk.
The chorda is separated from the undersurtace of the
malleus, and the malleus neck is cut with a malleus nipper
(Fig. 35 e) or, if the anterior malleal ligament is hyalinized,
with a 0.8 mm diamond burr (c.f. Fig. 58 e). The malleus
head and the chorda tensor fold are removed to ensure
,Sa free communication between protympanum and supratu-
bal recess.
Malleus nlpP6l'
35b
36a 36b
B.3 Myringo- and Ossiculoplasty

In Closed Cavities
8 .3.1 Myringoplasty
General Con sideratio ns

The terms underlay and overlay are used in relation to the
bony tympanic sulcus and not. as is usual . in reference to
the tympanic membrane, Therefore. anterior underlay
means that the temporalis fascia (or the piece of wet paper
used for it) is placed under the anterior tympanic sulcus in
contact with the lateral wal l of the protympanum. In this
case, Ihe tympanic annulus and anterior remnant of the
tympanic membrane remain over the anteriorly underlaid
fascia. Pos terior overlay means that the fascia is situated
over the posterior bony tympanic sulcus. When reposi-
tioned, the tympanic membrane remnant (or tympa-
nomealal flap) will cover the posteriorly overlaid fascia. 37
(j)
Underlay Grafting The graft is supported althe following points (Fig. 37):
For training purposes, use a wet piece of paper from the
surgical glove packing . An inciSion IS made with a knife <D On Ihe inferior tympanic sulcus.
according 10 the expecled position of the malleus handle @ Under the malleus handle.
(Fig. 36 a). <D On the posterior tympanic sulcus and the chorda
tympani.
The swinging-door Iympanomeatal flaps are elevated
(except antenorty between 2 and 4 o 'clock) 10 create suffi- @) In the gap created antero-superiorly between the
cient space for inserting the graft under the anterior margin tympanic annulus and tympanic sulcus.
of the perforation, The graft is placed under the malleus
handle and rests over the chorda and the pastero-inferior
tympanic sulcus (Fig. 36 b).
For subtotal or large anterosuperior perlorations, the graft
should also be fixed between the sulcus and annulus
tympanicus at the 1 0 'clock position for the right bone and
at the 11 o 'clock position for the left ear.
r ___-':F~,"':::h:mlCroraspatory
39.
38 39b
B.3.2 Ossiculoplasty
8 .3.2.1 Incus Interposition
8 .3.2.2 Autologous Incus
In the presence of intact stapes, malleus handle and ante-

rior half of the drum, the preferred type of reconstruction is
the interposition of the autologous incus.
Measuring the Length and Angle of the Implant

The correct length and angle of the implant is measured
using a Fisch microraspatory that is 2.5 mm in length.
Shaping the Autologous Incus

The incus body is held firmly using a small curved clamp
while drilling with a diamond burr (Fig. 39a). The long
process and the posterior part of the incus body are short-
ened. Keep in mind that the plane used to shorten the incus
body determines the angle of the interposed ossicle. The
articular surface of the incus is carved, taking into consid-
eration the inclination of the malleus handle (Fig. 39 b).
A notch for the stapes head is drilled on the opposite side
using 0.6 and 0 .8 mm diamond burrs (Fig. 39c).
40a 40b
Interposition of the Modified Autologous Incus

The modified incus is rotated in contact with the malleus
handle over the stapes head using the largest microsuction
and a 1.5 mm, 45° hook (Figs. 40 a, b). The chorda tympani
runs cranial to and stabilizes the interposed incus
(Figs. 40 a-c).
B.3.2.3 Titanium Incus
A Titanium Incus Prosthesis (KARL STORZ, Tuttlingen,

Germany) is used when the autologous incus is not avail-
able (Fig. 41 a). Prosthesis length selection (3, 4 or 5 mm)
depends on the measurement obtained with the Fisch
microraspatory (see Fig. 38). The prosthesis surlace con-
necting with the stapes head and malleus handle should be
rough. This is achieved by dri lling the contact surfaces with
a diamond burr. For this purpose, t he titanium incus should
be held wit h special incus-holding forceps (Figs. 41 b, c ).
The t itanium incus is transported into t he middle ear and
introduced between the malleus handle and stapes head
using a 2.5 mm, 45° hook inserted through holes made for
this purpose (Fig. 41d). The prosthesis is posit ioned exact- 41.
ly as an interposed autologous ossicle (Fig. 41 e).
2.5 mm Hook
.J
C>
1---
41.
41. 41< 41.

C Stapedotomy
Tympanoplasty
kmfe
Stapedotomy means the creation of a small calibrated
fenestration into the stapes footplate. The same name is
frequently used to indicate the introduction of a stapes
prosthesIs between the incus and vestibule, regardless of
whether the opening into the footplate is well calibrated or
consists of a partial removal of the footplate (~small fenes-
tra stapedectomyj. From t he authors' point of view, the
definition of "stapedotomyN should be limited to the former I
situation and the latter should be cal led a "partial
42. stapedectomy. N
The introduction of a stapes prosthesis from the malleus to

the vestibule has been called ~ vestibulopexy. " This term
does not address whether the prosthesis reaches the
B vestibule through a calibrated opening. or through a partial
or total stapedectomy. To avoid thiS confusion. the authors
have introduced the terms incus-stapedotomy and malleo-
stapedotomy for the exclusive use of a stapes prosthesiS
from the Incus or malleus handle in conjunction with a
" stapedotomy opening.
, ............ _--- "':': ~" To achieve a stapedotomy opening through the footplate
on a regular basis, It has proven of value to reverse the
classic steps of stapedotomy and to create the calibrated
opening before removing the stapes arch. In this case, the
42b diameter of the stapedotomy opening should not exceed
0.5 mm, and the corresponding diameter of the stapes pis-
ton should be of 0.4 mm.
IJ fA,; " -r r"'r··~~i~(

, C.1 Incus·Stapedotomy
~'''' f {T"""
Endaural Skin Incision
~ /-A",/.1e.w The endaural skin incision (A-B in Fig. 42 a) is made using
a No. 15 blade at the 12 o'clock position between the tra-
gus cartilage and root of the helix. The soft tissues are cut
to the level of the bony entrance of the canal (remove
excess soft tissues over the bony external ear canal to gain
sufficient exposure in the temporal bone specimen).
Tympanomeatal Flap
The tympanomeatal incisions are made with a NO.l1 blade
mounted in a special rounded scalpel handle.
The posterior limb of the tympanomeatal flap begins at
8 o 'clock, ascending spiraly from the tympanic annulus
to the lateral edge of the external auditory canal (C-A in
Fig . 42 b). The anterior limb is carried out from the 1
o'clock position to the Inferior edge of the endaural incision
(D-A in Fig. 42 b).
NOTE: A larger tympanomeatal flap (as for malleo-stape-

dotomy, see page 28) is used whenever total or partial
fi xation of the malleus is suspected.
v< "" "",,g, ~w.
l)..,."", ~ /
~ <J , ,....L. , f<-r:J a.- ,.-;~ .
~ Te~porar Bone Dissection - The Zurich Guidelines 23
Canalplasty 43b
While elevating the tympanomeatal flap, the bony over-
hang of a prominent tympanosquamous spine or a pro-
truding antera-superior canal wall needs to be removed to
adequately inspect the anterior malleal process and
ligament (Figs. 43a--c). A curette or diamond burr is used
for this purpose (do not separate the Iympanomeatal flap
from the tympanic sulcus and incisura Aivini during this
step to avoid irrigation of the middle ear with contaminated
Ringer's solution).
Elevation of Tympanomeatal Flap

The most important landmark in this step is the posterior
tympanic spine (posterior end of the incisura tympaniea
Aivini). The Iympanomeatal flap is elevated first from t he
43<
posterior spine using a Fisch microraspatory. Care is taken
to keep the chorda attached to the flap (Fig. 44 a).
Enlargement of the Supero- Posterior Canal Wall

The bone covering the oval window, the inferior edge of the lateral
incudo-malleal joint and the anterior malleal process are
removed using a curette. The rotational movements of the +••
curette should be directed from medial to lateral to avoid
trauma to the chorda and incus (Fig. 44 b).
.•~--~~
•
medial
,
" 440 44"
Anterior maJleal
ligament
Pyramidal ~~
45 process Stapedial tendon 46
Exposure of the Oval Window

The exposure of the oval window is correct when the fol-
lowing structures are visible (Fig _45):
• Pyramidal process with the stapedial tendon

• Oval window with the stapes and incudo-stapedial
joint
• Tympanic segment of the facial nerve
• Infenor incudo-malleal JOint
• Lateral (short) process of the malleus
• Anterior malleal process and ligament
Preparation of the Stapes Prosthesis

A malleable measun'ng rod is used to determine the dis-
47 tance between t he footplate and the lateral surface of the
incus (Fig . 46), This measurement should be increased by
0.5 mm to account for the protrusion of the prosthesis pis-
ton into the vestibule. The resulting total length of the pros-
thesis will average 5.2 mm. A 0.4 x 8.5 mm Titanium Stapes
Prosthesis (KARL STORZ. Tuttlingen. Germany) is trimmed
on a special Titanium Cutting Block (Fig. 47) and placed in
the preformed 0.4 mm hole for later use.
The stapes prosthesis is available in two other sizes: 0.4 x
10 mm and 0.4 x 7 mm. The longest prosthesis is used in
deep middle ears (partially malformed ears), the shortest in
shallow middle ears (partially open cavities). The different
lerJgths relate to the different distance between prosthesis
loop and 0.4 mm cylinder.
> 1 mm_.:.j
Perforation o f the Foo tplate
< lmm---
A calibrated opening of 0.5 mm diameter is made in the
... safe area (the central area between the middle and inferior
third of the stapes footplate) where the saccule and utricle
lie more than 1 mm below footplate level (Fig. 48 a). The
stapedotomy opening should be positioned in such a way
that the prosthesis will remain perpendicular to the foot-
plate .
•
Temporal Bone Oissection - The Zurich Guidelines 25
Manual perforators
Caliper (0.4 mm)
0.3 0.4 0.5 0.6
48"
A set of four manual perforators (0.3, 0.4. 0.5 and 0.6 mm

diameters. Fig . 48b) is used to create the stapedotomy
opening. The perforators are rotated back and forth
between thumb and index finger. The tip of each perforator
is only partially introduced into the vestibule. The correct
size of the opening (0.5 mm) is con firmed with a 0.4 mm
caliper (Fig. 48 c).
Introduc tion and Fixatio n of the Stapes Prosthesis

Large smooth
The stapes prosthesis is picked up from the cutting block alligator forceps
using large straight smooth alligator forceps (Fig. 49 a). The
piston IS first placed over the stapes footplate and aligned
with the long process of the incus. The length of the pros-
thesis is correct if the piston loop exceeds the la teral sur-
face to the incus by 0.5 mm (Fig. 49 b).
II the prosthesis is the correct length, it is moved over the
stapedotomy opening with a 1.0 mm. 45° hook and care-
fully advanced into the vestibule (Fig. 49 b). The loop is
then crimped over the incus with small straight smooth
alligator forceps (Fig. 49 c).
49.
1.0 mm. Small smooth

45' Hook alligator forceps
•
491> 49c
Chorda tympani
Tympanoplasty
Jomt knife
SO. SOb
Removal of the Stapes Suprastructure

With the prosthesis in place, the incudo-stapedial joint is
separated with ajelnt knife (Fig . 5Oa). the stapedial tendon
is sectioned with tympanoplasty microscissors (Fig. 50 b),
the posterior crus is cui with cruratamy scissors that are
controlled with both hands (Fig. 50 c), and the anterior crus
is crushed at the level of the footplate with a 2.5 mm, 45°
hook (Figs. 50 d and e).
The stapes arch is removed, and final mobility of the ossi-
cular chain is confirmed. There should be no free move-
ment of the prosthesis loop when either the incus or
malleus is moved (Fig . 50 f) ,
Crurotomy
scissors
50e ----.
1.5 mm Hook
2.5 mm Hook
SOd
,
Temporal Bone Dissect ion - The Zurich Guidelines

27
1.5 mm 45~ Hook

Venous
blood
'10 51b
Sealing of the 5tapedotomy Opening and

Repositioning of the Tympanomeatal Flap
Three connective tissue pledgets from the endaural inci-
sion are placed around the stapedotomy opening (Fig. 51 a)
Venous blood obtained from the cubital vein of the patient
prior to surgery and one drop of fibrin glue are used to seal
the oval window niche (Fig. 51 b). The tympanomeatal flap
is repositioned, and two small Gelfoam ™ pledgets soaked
in corticosporin are used to keep the flap in poSit ion
(Fig. 52).
Fibrin
"""
'10
o
o
o ;:~.,~",~",;:_
.
'' ", '"
,....' •"-'''','
'I":'
,"
(''''
.,.
.', • •.
Gelfoam and
Ot ospofln
. 0,
'.
";'
••
.'•'.••.,,.
;:;"
,
"•
.
'".' .
•
." '.• •'
, ....'
•'
o
52
Spina tympani
anteoor
A . .. ~
..•...•• .....
. ,- ' -•." : 0 D
A
••
•
...
•••••••••
'.'. '. .:~,.--------"

-._---
C
53 54 Spina tympani
posterior
C.2 Malleo·Stapedotomy completmg the canalplasty to avoid contamination of the

middle ear cavity with contaminated saline solution used
for irrigation while drilling .
Endaural Approac h
This surgical step is identical to incus stapedotomy (Fig.
Antero-superior Canalplasty
423, page 22).
The canal skin is elevated from the wall of the ear canal
with a Fisch microraspatory. The antero-superior overhang
Tympanomeatal Flap of bone is then removed with sharp and diamond burrs
The tympanomeatal flap used for malleo-stapedotomy is until the anterior and posterior tympanic spines can be
larger than that described for incus-stapedotomy. The pos- identified (see also Fig. 43 b, page 23). The tympanomeatal
terior limb (C-B. Fig . 53) is the same, but the anterior limb flap should remain attached to the bone at the entrance of
(D-B. Fig. 53) extends to 4 o'clock on the right side and the middle ear until drilling is completed to avoid contami-
8 o'clock on the left. nating the cavum tympani with irrigation fluid.
The soft tissues are elevated from the underlying bone
using a Key raspatory. At t his stage, the endaural ret ractors
Elevation of the Tympanomeatal Flap
are replaced to obtain maximal exposure wit hout injuring
the skin margins (this surgical step does not apply to the The tympanomeatal flap is first elevated from the posterior
temporal bone). The tympanomeatal flap is raised from the tympanic spine using a left Fisch microraspatory (right ear)
underlying bone with a Fisch microraspatory and a micro- that is introduced under the rim of bone lateral and superi-
suction tube (Fig. 15, page 10). In Figure 54, the anterior or to t he chorda tympani. The Shrapnell membrane is then
and posterior tympanic spines are exposed for anatomical elevated from the malleus neck and lateral malleal process
demonstration. In reality, the tympanomeatal flap should until the anterior tympanic spine and t he beginning of the
not be separated from the Incisura tympanica Rlvini before anterior tympanic annulus become visible.
Antenor maBeal process
Lat"""
malleal
process
Antenor
malleal
ligament
Spma tympani
posterior
55 56 ho,,'~ tympani
Antenor malleal process

Antenor tympanIC
""M
M Incudo
malleal
, jOint
, I
57, Pyramidal 57.

process
Exposure for Malleo-Stapedotomy Removal of Incus and Malleus Head

The correct exposure for malleo-stapedotomy is obtained The malleo-stapedotomy is performed when there is total
by using a curette to enlarge the supero-posterior edge of or partial fixation of the malleus and/or incus. A fixed incus
the bony external canal (see Fig. 44, page 23). The follow - is removed after cutllng its loog process with a malleus
ing structures should be exposed (Fig. 57 b): nipper to avoid damage to the chorda tympani during
extraction (see also Fig. 35 c, page 18). The malleus nipper
is not used to section the malleus neck because this
• Pyramidal process with the stapedial tendon maneuver would leave the anterior malleal process intact
• Oval window with the stapes and incudo-stapedial (Fig. 58 b).
Joint
• Tympanic segment of Fallopian canal
• Inferior part of the incudo-malleal loint
• Lateral malleal process and malleus neck CalCi fied anterior
• Anteri or malleal process and ligament malleal ligament
• Anterior tympanic spine
The corda tympani should be kept intact whenever possi-

ble. Remember that an intact chorda is the calling card of
the otologist.'
58a
Malleus nipper
•
A fixed malleus head is removed most effectively by cutting

Its neck with a 0.6 or 0 .8 mm diamond burr (Fig. sac).
While drilling. the malleus handle is held with a large
toothed straight alligator forceps controlled by the left
hand . The drilling starts over the anterior malleal process,
which is just anterior to the lateral process (Fig . SSe) and
•
continues in a superior and antero-poslerior direction
across the malleus neck. This C· shaped line of drilling per-
mils the anterior malleal process to be included in the
resection. Great care is taken to keep the chorda tympani
intact. The chorda tympani runs under the anterior malleal
process from which it must be separated by using a hook
prior to drilling.
: ::::::
Preparation of the Stapes Prosthesis
The previously mentioned Titanium Stapes Prosthesis,
0.4 mm diameter and 8.5 mm length, is used for both
incus-stapedotomy and malleo-stapedotomy. The initial
steps for preparing the prosthesIs are the same for both
types of stapedotomy (see page 24). The average distance
between the proximal malleus handle and the stapes foot-
plate is 6.5 mm (including 0.5 mm to allow for protrusion of
the piston into the vestibule). The Titanium Stapes
ProsthesIs is trimmed on a titanium cutting block (Fig. 59).
The surface of the cutting block should be humidified with
saline solution to eliminate unnecessary movement of the
prosthesis. The diameter of the prosthesiS loop is enlarged
to the size of the malleus handle by moving it along a
1.5 mm, 45 0 hook with watchmaker forceps and then
stored in the 0.4 mm hole of the cutting block.
Shapin9 of Prosthesis-Shaft for the Malleus Handle

The shaft of the prosthesis may be bent along various
planes on the cutting block to accommodate the anterior
position of the malleus. This is done while the prosthesis is
in t he 0.4 mm hole of the cutting block by genlly bending it
to the correct extent by pushing the shaft with watchmaker
forceps (Fig. 60). This same maneuver can be performed in
a lateral d irection if required by the steep position of the
malleus handle.
59 60
Perforation of the Footplate

This step is performed using manual perforators as for an
incus-stapedotomy. An Erbium-YAG laser is used in spe-
cial cases (e.g. mobile foot plate).
Removal of Stapes Arch

The stapes arch is removed after perforation of the loot-
plate. Both crura are cut using crurotomy scissors (see
Fig. 50 c , page 26). The stapedial tendon is cut last to
insure stability while cutting the crura.
Introduction and Fixation of the Stapes Prosthesis

The picking up and the introduction 01 the prosthesis in the
middle ear are done in a manner similar to incus-stapedoto- Titanium stapes
prostheSIs
my (see Fig . 49, page 25). The exposure given by the large (0.4 mm diameter)
tympanomeatal flap and the anterosupet'lor canalplasty is
such that both, the malleus handle and the footplate are
visible with one position of the microscope. The prosthesis
."
is first placed on the footplate to ensure that the length and
bend are adequate (the prosthesis cylinder must be perpen-
dicular to the foot plate). The prosthesis cylinder IS then
introduced into the vestibule for 0.5 mm (measured from the
lateral surface of t he footplate) using a 1 mm, 45° hook.
Fixation of Stapes Prosthesis

The prosthesis loop is attached to the malleus handle just
distal to the lateral malleal process (Extensive separation of
the drum from the malleus handle should be avolded.~ .
Crimping the prosthesis to the malleus handle is performed
uSing large (Fig. 61 a) and small smooth straight alligator
forceps (Fig. 61 b). Each forceps is held with both hands.
The prosthesis loop should be immobile after crimping.
Sealing of the Stapedotomy Opening and Repositioning

of the Tympanomeatal Flap Titanium stapes
prosthesis
.,.
These surgical staps are done as for incus-stapedotomy (04 mm diameter)
(see Fig. 51, page 27).
•
o Open Cavity (Open Mastoido-

Epitympanectomy or Open MET)
The surgical principles of an open MET are:
<D rad/cal exenteration and

CD adequate exteriorization
of the pneumatic cell tracts. In clinical sit uations, the open
MET is often associated with partial obliteration of the cav-
ity using an occipital myosubcutaneous flap (METQ. or
Mastoidectomy, Epilympanectomy, Iympanoplasty and
Qbliteration with myosubcutaneous flap). The first steps of
an open-cavity procedure (Retroauricular Skin Incision and
Canalplasty) are the same as for a closed-cavity tympano-
mastoidectomy. If two temporal bones are used for the dis-
1 section, the bone available for performing the open-cavity
62 procedure was already used for the incus- and malleo-
stapedotomy. Therefore, a modified meatal skin flap must
be used for the canalplasty.
Checklist for Bone Work In Open MET

The recommended sequence of bone removal for an open
MET is (Fig. 62):
<D Wide lateral bone removal over the root of the zygoma
with skeletonization of the middle cranial fossa dura
and sigmoid sinus, exposure of digastric muscle, and
skeltonizallOn of stylomastoid foramen.
® Identification of the tympanic segment of the fallopian
canal and posterior bony semicircular canal, and low-
ering of the facial ridge.
CD Radical exenteration and extenonzation of the retrofa-
MC'
Dura cial. retrolabyrinthine and the retrosigmoid cells.
RetrOSlgmold
<D Radical exentera tion and exteriorization of the epitym-
cells panum (supral abyrinthine and supratubal recesses).
® Extended antero-inferior cana/plasty.
63
Sigmoid SinUS
0.1 Mastoidectomy
Lateral Bone Removal
Mastoidectomy begins with wide removal of lateral bone
from the zygomatic arch to the sinodural angle (Fig. 63).
The dissection is continued with skeletonization of the mid-
dle cranial foss dura, the sigmoid sinus and sinodural
angle. The lateral semicircular canal is identified in the
antrum and the lateral surface of the digastriC muscle is
exposed (Fig. 64).
Epitympanotomy
The antrum is opened and the dissection is extended ante-
riorly to periorm an epitympanotomy (Fig. 64 and Fig. 28,
page 15). The tympanic segment of the facial nerve is iden-
Digastric tified at t he inferior edge of the lateral semicircular canal
muscle
(see also Fig. 32, page 17). The bone at the mastoid tip
covering the lateral suriace of t he digastric muscle is
removed. No bony overhangs along the d issection field
should remain (particularly over the middle cranial fossa
64 dura and behind the sigmoid sinus).
TympaniC segment
of facial nerve
~(_Stylomastoid
::.- fOl"amer1
/
of
canal
65 66
Stylomastoid
foramen
Stylomastoid
periosteal
fibres
Mastoid Tip Surgery and Facial Nerve Identification

The superior edge and the lateral surface of the digastric
muscle is followed until the stylomastoid periosteal fibers
are visible. The stylomastoid foramen is identified and the
bone along and lateral to the white periosteal fibers is
removed (Fig . 65). At this stage, a crack forms lateral to the
stylomastoid foramen , mobilizing the remaining mastoid lip
(see Fig. 71 , page 35), 2
Lowering of the Facial Ridge

67
The posterior semicircular canal is identified. The three
essential landmarks are now visible, determining the posi-
tion of the mastoid and pyramidal segments of the facial
nerve (Fig. 66). These are:
ill the tympanic segment of the facial nerve

<D the inferior edge of the posterior semicircular canal,
and
<D the stylo-mastoid foramen .
•
The anterior remnant of the superior canal wall is removed

10 fully expose the ossicular chain .
67. .7.
•
Completion of Mastoidectomy
The incus is disarticulated from the stapes, and Ihe incus
and malleus are removed. If the malleus handle can be
preserved, the tensor tympani tendon should also be
preserved to stabilize the latter. The retrofacial (1), the
retrolabyrinthine (2) and the retrosigmoid (3) cel l t racts are
exenterated and exteriorized. The jugular bulb is skele-
tonized (Fig . 67: Inserts a and b)
Sinus epitympani
' .........
,
I
I
68 69
0.2 Epitympanotomy
Epitympanotomy
The supralabyrinthine (3) and supratubal (4) recess are
exenterated and exteriorized to expose the ampullary end
of the lateral and superior semicircular canals (Fig. 68). The
awareness of the close proximity of the labyrint hine and
tympanic segments of the facial nerve prevents injury of
the geniculate ganglion (5).
0.3 Completion of Mastoido-

Epitympanectomy
Exteriorizatio n of Antero -Superior Cavity

An extensive antero-inferior canalplasly is per10rmed to
remove all bone overhangs at the root of the zygomatic
arch (Fig. 69: Insert). The tympanic bone should be low-
ered to meet the level of the stylomastoid foramen (6).
A diamond burr is used when neanng the mandibular
condyle while watching for color changes that indicate its
proximity.
New Tympanic Sulcus

If there is no remnant tympanic annulus, drill a new tym-
panic sulcus (Fig. 70, (7)) in the bony canal wall from the
1 to 9 o'clock poSItions (right side). The resulting bony
ledge will accommodate the fascial graft used for myringo-
plasty. The profile and position of the new ledge are shown
70
in the inserts shown in Figure 70.
If an anterior tympanic membrane remnant is present , the
new sulcus is performed from 4 to 9 o'clock because the
tympanic annulus is left in sil u along the sacred anten'or
tympano-meatal angle (see Figs. 25, 26 and 36).
Gelfilm or
thick silastic
I
I
71 72a
Mastoid T ip Removal MicrosuClIOn N' 2

The mastoid tip is removed with rongeurs along the frac -
ture line produced during identification of t he stylomastoid 2.5 mm. 45~ HooI<
foramen (see Fig. 72 a). The rongeur is rotated from medial
to lateral, and a large curved scissors is used to separate
the soft tissues attached to the undersuriace of the mas-
toid tip.
E. Tympanoplasty (Myringo- and

Ossiculoplasty in Open Cavities)
E.l. Type III Tympanoplasty
This type of reconstruction is periormed in the presence of
an intact mobile stapes. If a portion of the anterior tympan- 72b
ic membrane remains intact, an anterior fascial underlay is
used, If no tympanic membrane is left, an overlay graft
becomes necessary (an overlay being a graft placed over
bone; i.e. , over the old or new tympanic sulcus. limiting the New Tympanic
aerated middle ear space; see also B.3. 1. Myringoplasty, Sulcus
Genera l Consid eratio ns, page 19).
Myringoplasty with Anterior Fascial Underlay

A thick (1 mm) Silastic· sheeting (Getfilm fM is used in the
presence of an active infection) is introduced into the mid-
I dle ear up to t he tympanic ost ium of the eustachian tube
(Fig. 72a).
) A fresh temporalis fascia (a wet piece of paper in the labo-
ratory) is placed under the anterior remnant of the tympan-
ic membrane (underlay grafting) over the new tympanic
sulcus inferiorly. and over the facial ridge and tympanic
segment of the fallopian canal postero-superior (Fig. 72 b).
The stapes head should be higher than the surrounding
fascia (outward bulging. Fig. 72 c). If the stapes head is too
low. a piece of tragal or conchal cart ilage with a notch is
used to increase its lengt h.
",
Temporalis
Fascia
73. 73b
When the tympanic membrane is absent, a thick (1 mm)

$ilaslic sheeting is introduced into the middle ear to avoid
scar tissue formatIon between the fascia and mucosa
(Fig . 73 a), The fresh temporalis fascia (or tragal perichon-
drium) is then placed over the circumferential new tympan-
ic sulcus, the tympanic segment of the fallopian canal and
the semicanal of the tensor tympani muscle (overlay graft-
ing) (Fig. 73 b),
74. 74b
E.2 Total Reconstruction of the
Ossicular Chain
E.2.1 The Fisch Titanium Total Prosthesis
E.2.1.1 Preparation of Prosthesis

The Fisch Titanium Total Prosthesis (FTTP) is composed of
Holding forceps an L-shaped shaft with head and a shoe (fOOl) with spike
(Fig. 74 a, b). The distance between the tympanic mem-
brane and the footplate is determined with the malleable
measuring rod. The FTTP can be used with or without the
shoe.
740
Prosthesis w ith Shoe
If the shoe IS used, 0.5 mm should be subtracted from the
total measured length to account for the additional length
of the shoe in the assembly.
Blood or The FTTP shaft is introduced in the 0.6 mm hole of the
"".._ _ _...., fibrin glue Titanium Cutting Block (see Fig . 59) and trimmed to the
desired length (Fig . 74 a). The foot is placed into the
1.0 mm hole of the cutting block (Fig. 74 b). The F I I P shaft
is grasped with a special curved holding forceps and intro-
duced into the shoe (Fig. 74c). A drop of blood or fibrin
glue can be used to increase the stability of the assembled
prosthesis (Fig . 74 d).
If more strength is required, a special crimping forceps can
be used to squeeze the foot tightly to the shaft.
74<1
Prosthesis with Cartilage Disc Vertical plane
The mp is used without a shoe if the oval window is too

narrow or the stapes arch remains in place, The shaft alone
is also used if the patient does not accept the risk to the
. ••
••
inner ear deriving from the introduction of the shoe's spike ••
in the vestibule. If the shoe is not used. stabIlIzation of the :
shaft IS obtained by using a cartilage disc (see Figs. 80 and
8t , pages 39, 40).
r
E.2.1.2 Shaping the Prosthesis Head
Angulation
The thickness of the FTIP head is only 0.1 mm. Therefore. 75.
the plane of the prosthesis head can be adapted to the
drum position in the vertical and horizontal planes (Figs.
75a and b).
•••
4•
Horizootal plane
. \
••
Size and Shape
•• •••
•
1 ~
The mp head is 0.' mm thick and 5 mm in diameter.
Special titanium scissors can be used to reduce the dia-
meter of the prosthesis head to 3 or 4 mm by cutting away
one or two outer rings (Figs. 76a, b and c).
It is also possible to remove the anterior half of the pros-
thesis head (when the malleus handle is present) or to give
It any desired shape (Fig. 76 d).
75b
5mm
, mm
7. . 760
3mm
• •
.
•
? Scissors for titanium
total prothesis
76c 76d
•
00 l e ngth of L-s ha pe d Arm

° 00 °<>00 <>
Another unique feature althe FTTP is the ability to change
the length of its l-shaped arm to meet the specific require-
ments of the middle ear anatomy. particularly when the
prosthesis head is reduced in size. For this purpose, the
FTTP is grasped with two watchmaker forceps and
straightened, then bent in the deSired angle as shown in
Fig. 77 a-d.
E.2.1.3 F I I P Handling
'70
Ho lding Forceps and Micro suction Tube
The FTTP is transported from the cutting block to the
middle ear with special curved holding forceps or with the
largest microsuction tube.
77'
77, 77'
_ Mk:rosuction
,"be
Holding
forceps
,.
,
-- ... .
•
.
.' .
'", .,
."
"'//
'\ '
79. 79b
Rotation of the Head of F riP under the Drum Stabilization of the F II P on the Stapes Footplate.
Use of Shoe with Spike
The loot of the FTIP is fixed with the spike on the central
part 01 the footplate. The FTIP head is then rotated into The best stabilization of the FTIP to the foot plate is
positioo by raising the pars tensa with a 2.5 mm. 45° hook achieved by perforating the central part of the stapes fool-
held in the left hand, while a second hook (1 .5 mm, 45°) IS piate to allow introduction of the 0.3 mm long spike of the
manipulated by the nght hand to rotate the prosthesis head prosthesis shoe (Fig. 60 a). The perforallOn is made with
using one of its multiple central holes. The final position 01 the smallest manual perforator. A mobile footplate is fixed
the prosthesis head is under the central pars tensa, pro- during this maneuver with a 1.0 mm, 45° hook held in the
ducing a slight bulging of the latter as a sign of sufficient left hand, which pushes the footplate slighty against the
tension to keep the prosthesis in the deSired position (Figs. margin of the oval Window. An Erbium-VAG laser can also
79 a and b). There IS no need to cover the prostheSis With be used to perforate a mobile footplate. Usually one single
cartilage because the prosthesis head can follow the pulse of 35 mJ is sufficient for this purpose.
movements 01 the tympanic membrane because 01 the
flexibility of the 0.2 mm diameter angled titanium band
connecting it to the shaft.
Tragal cartilage
h.) Tragal cart ilage
o
"
....'
,O'
,.. ,'".
• •
...
,.,.., ••
•
•• .
~ ,.,.
•
",' •• .,.'
'
'"
, I
, ,t,
•
-h~
-,'
,#
4'' .I' 'I
"
., ,II
'
••
••
••
• ,#
..
.' I'
·h-
/' '/
••
-"
•••
80b 80c
Endaural
skin InciSIOn
Tragal
,~ ___ ~___~ cartilage
.'
\ L~--_'
'
'«')"
81. 81b
0.6 mm
diamond burr
8" 8"
_ _ _ Anatomical
forceps
f---=O~/ } , mm
3mm
81. 8"
Shaft without Shoe

Special holding
forceps
Nearly equal functional results have been obtained by plac-
ing the shaft of the FTTP without a shoe on the footplate.
In this situation, however; a cartilage disc of 1 mm thick-
ness obtained from the tragus or from the conchal cartilage
must be used for stabilization. The cartilage disc has to fit
tightly within the oval window niche. The technique used
for the harvesting and preparation of the cartilage disc is
shown in Figs. 81 a-g .
When the stapes arch is intact, the F II P is a/so used with-
out a shoe. In this case, the stabilization is achieved by
wedging small pieces of cartilage (from the tragus or con-
cha) between the wall of the oval window niche and the
81, prosthesis (Fig . SOc).
Temporal Bone Dissect ion - The Zurich Guidelines 41
E.2.2 Fisch Titanium Neo-Malleus
This technique is utilized In absence of malleus, incus and
stapes arch, when the stapes footplate is fixed or when
another type of total reconstruction of the ossicular chain
has failed to improve the function of a mobile stapes. Neo-
malleus reconstruction is usually performed in two stages
- at an interval of three to six months,
First Stage
A piece of tragal perichondrium is obtained through the
endaural approach (Figs. 61 a-<:). A rectangular piece of
82.
perichondrium is cut slighlly longer than the supero-inferior
diameter of the drum. The 5 mm long titanium neo-malleus Stapes only
is introduced over the lateral surface of the graft through (fi_ad or mobile)
two small incisions (a No. 11 blade with rounded scalpel
handle, graft on glass platform IS used) (Figs. 62 a, b).
The perichondrium with the attached neo-malleus is intro-
duced under the partially elevated tympanic membrane
and is anchored inferiorly through the gap created at 6 0'
clock (right side) between t he tympanic annulus and SUl-
cus. The perichondrium will rest superiorly as an overlayed
graft between the superior canal wall and the tympa -
nomeatal flap. The titanium neo-mal/eus is aligned over the
oval window (Fig. 62 c). 82b
Second Stage
The second stage is performed three to six months later
if no signs of tubal dysfuction have appeared. The tympa-
nomeatal flap IS elevated and the superior end of the
implanted neo-malleus is identified. The nee-malleus has
various grooves for fixation of the loop of a stapes prosthe-
sis. Only one of these indentations and not the complete
superior end (as shown in the pict ure) is exposed to avoid
excessive movement and to keep the neo-malleus in the
desired position. A 0.5 mm stapedotomy is performed
(using manual perforators or a laser) in the center of the
(fixed or mobile) footplate (Fig . 63 a).
The Titanium Stapes Prosthesis is brought into place. intro-
duced 0.5 mm from t he lateral surface of t he footplate in
the vestibule, and crimped on the titanium neo-malleus
using smooth small straight alligator forceps (Fig. 63 b). The
82,
stapedotomy hole is sealed with three connective tissue
pledgets, venous blood from the cubital vein, and fibrin
glue (see Stapedotomy Figs. 51 a-c, page 27).
• Eustachian t ube
GeniCulate
gangioo
. Pericarolld celts Internal carot id
Supra tubal cells .rt"Y
Internal Lateral
Supra· carotid ar1ery semiCircular
Jabynnth lne
cells ~----- "'"'"
Supenor
Retro-
, semiCircular
canal
Jugular
bulb
Posterior
semicircular
canal
Retrolacial cells
•
Retrosigmoid cells
84 85
traumatic nature (e.g ., following transverse fractures of the

F Additional Temporal temporal bone). to introduce CI in sclerotic temporal
Bone Dissection bones, or when there is a meningitiS risk due to a possible
CSF leak.
Exenteration of Pneumatic Cell Trac t s
Additional temporal bone dissections may be carried out at
the end of the procedure. They represent a transition from The cell tracts of the middle ear cleft (Fig. 84) are exenter-
temporal bone to lateral skull base surgery. ated in the follOWing order: retrosigmoid, retrofacial, retro~
labynnthine, supralabynnthine, supratubal, infralabyrinthine
In the authors' opinion, these dissections belong within the and pencarotld.
curriculum of a modern otologist. who in fact should not
remain a middle ear surgeon, but become a temporal bone Most of these cellular tracts have been dealt with when
surgeon. per10rming an open MET.
In fact. an open~cavlty procedure performed according to
the authors' surgical principles is a ~subtotal petrosecto~
my," with the exception of the infcalabyn'nth/ne and peri~
F.1 Subtotal Petrosectomy (SP) carotid cells that are left intact.
The principle of SP is "the complete elimination of the Surgical site following exenteration of pneumatic cell
pneumatic middle ear cleft associated with the permanent tracts and preservation of the otic capsule
occlusion of the isthmus of the eustachian tube The cavi-
W
•
The pneumatic cell tracts of the temporal bone (with the
ty may be left open or be obliterated (with pedicled muscle exception of the apical) are removed (Fig. 85). To make
flaps or free abdominal fat grafts). In the latter case, the sure that no cells are left behind . the jugular bulb and the
EAC is closed in two layers as a blind sack. vertical intra temporal carotid artery are skeletonized.
There are two types of subtotal petrosectomy, one with The tympanic segment of the facial nerve is also skele~
OfesecvatlQQ the other with removal of the otic capsule tonized until the geniculate ganglion and the greater super-
ft
(For more details see: "Microsurgery of the Skull Base ficial petrosal nerve are identified. Note that the
U. Fisch and D. Mattox, Georg Thieme Stuttgart New York labyrinthine segment of the facial nerve is medial to and
1988). covered by its tympanic segment. and that the proximal
tympanic segment and the geniculate ganglion form a bor-
der between the supratubal and supra labyrinthine recess~
es. The otic capsule and, therefore. inner ear function are
F.1,1 Subtotal Petro sectomy with preserved.
Preservation of the Otic Capsule Pericarotid cells and obliteration of the eustachian tube
The vertical segment of the intratemporal carotid artery
General Considerations (ICA) is exposed to the bend indicating the beginning of the
horizontal segment Note that the isthmus of the eustachi-
This operation is is per10rmed to remove extensive tempo~ an tube is below and anterior to the ICA. The semicanal of
ral bone cholesteatomas, adenomas, extensive facia l the tensor tympani muscle covers part of the posterior
nerve neuromas, angiomas and Class B paragangliomas. It aspect of the horizontal segment of the ICA. Remember
is also used to seal congenital CSF leaks and those of a that the ICA may be dehiscent along the medial wall of the
protympanum (Fig. 86). The anterocarotid pneumatic cells Isthmus of Eustachian tube
can extend into the pyramid apex, and their exenteration
may require precise work with a diamond burr. When all Semlcanal of the
pericarotid cells are exenterated, the isthmus of the tensor tympani m.
eustachian tube is ready for obliteration with bone wax.
•
F.1.2 Subtotal Petrosectomy with

Removal of the Otic Capsule
86
General Considerations Oehiscent internal carotid artery
The otic capsule is removed to gain access to lesions
situated along the medial aspect of the inner ear spaces
(e.g., supralabyrinthine and infralabyrinthine-apical choles-
teatomas, and temporal paragangliomas class C3-4 Del-
2,Oi 1-2). The SP with removal of the otic capsula is also
part of the transotic approach used for acoustic neuromas
associated with a total loss of hearing. Remember that SP
with removal of the otic capsula is not a transcoch/ear
approach. The transcochlear approach (House WF,
Hitselberger WE: The transcochlear approach to the skull GenICulum of
facial nerve Supratubal recess
base, Arch Otolaryngol 1976, 102: 334-342) coosists of the
removal of the cochlea and posterior rerouting of the facial
nerve, leaving the middle ear and fAG intact. (For more Supralabyrinthlr"18
details 00 the SP with and without removal of the otic cap-
sule, see Fisch U. Mattox D: Microsurgery of the Skull Base,
...,'"
Thieme Stuttgart and New York 1988). Lesioos requiring SP
With removal of the ollc capsula involve the dura and, there- Labynnlhlr"18 ~
segment ...
fore, require obliteration of the pneumatic middle ear cleft.
01 facial nerve
Removal of the Posterior Otic Capsula (Labyrinth)

The semicircular canals are removed as in a trans/aby-
rinthine approach (Fi9 . 87).
The tympanic and labyrinthine segments of the facial nelVe
must be watched. Removal of the cochlea continues until Tympanic segment
the medial wall of the vestibule, the posterior ampullary and 87 of facial nerve
the superior ampullary nelVe become visible. The
labyrinthine segment of the facial nelVe is identified 2 mm
anterior and 2 mm lateral to the superior edge of t he internal
auditory canal. The posterior wall of the internal auditory
canal is skeletonized to the porus acousticus internus
(Fig. 88).
Petrosal nerve Removal of the Anterior Otic Capsula (Cochlea)
Apical turn Sketetonize the mastoid segment of the facial nerve and
Medial wall of cochlea the jugular bulb. Follow the lugular bulb as far as possible
of vesllbule medial to the facial nerve toward the round window niche.
Middle turn
Labyrinthine of cochlea Remove the bone covering the basal, middle and apical
,..menl turn of the cochlea (the apical turn may be covered by the
ollacial nerve semicanal of the tensor tympani muscle) working anterior
Basal turn
of cochlea to the fac ial nerve (Fig. 68). Skeletonize the inferior and
Internal anterior walls of the internal auditory canal until you reach
auditory the anterior porus. Note that the internal auditory canal is
canal situated deep and antenor to the skeletonized tympanic
and mastoid facial nerve.
Expose the posterior fossa dura between the internal audi-
Posterior tory canal, superior petrosal sinus (medial to the semicanal
ampulla!)' of the tensor tympani muscle), vertical carotid artery, and
nerve jugu lar bulb (Fig. 89). Opening this dura would lead in the
..
anterior cerebello-pontine angle. This is what is done in the
Posterior fossa dura transotic approach. which is the only approach permitting
the surgeon to first separate the intracranial segment of the
facial nerve from the anterior pole of the tumor.
Final surgical site of SP with removal of the otic capsula

Horizontal segment
of ICA The complete medial wall of the temporal bone is
Isthmus of Eustachian tube exposed between sigmoid sinus, superior petrosal sinus
(separating dura of the middle and posterior cranial fos-
VertiCal segment
of ICA sa), internal carotid artery and Jugular bulb. The cell
tracts located medial to the otic capsula and extending
Carotid
toward the pyramid apex have been completely exenter-
foramen
ated (Fig 89).
Jugular
Middle bulb
cranial •
fossa dura
,,
P,,""o' G Suggested Reading
ampulla!),
(singular) nerve
The fo llowing books and papers contain detailed informa-
tion on the microsurgical techniques presented in this
/"-..1' Posterior fossa dura manual:
Book s
Sigmoid sinus
U. FISCH in collaboration with J. MAY: Tympanoplasty.
Mastoidectomy. and Stapes Surgery. (1" edition. 1994,
Cl Georg Thieme Stuttgart - New York).
U. FISCH, J. MAY, 1. LINDER: Tympanoplasty,
Mastoidectomy, and Stapes Surgery. (2"" edition, forth-
coming 2006; approx. 320 pp, 36 tables, approx. 155 illus-
trations, hardcover. ISBN 158890167x I 313137702x;
C Georg Thieme Stuttgart - New York).
A. POSADA: Spanish translation of Tympanoplasty,
Mastoidectomy and Stapes Surgery 1998
A. POSADA: Spanish translation of the Course Book of the
Fisch International Microsurgery Foundation. 2002
U. FISCH, D. MATIOX: Microsurgery of the Skull Base,
1988 10 Georg Thieme Stuttgart - New York, 2000
© Thieme Classic Edition
R. POSADA: Spanish edition of Microsurgery of the Skull
Base 1998
Papers
U. FISCH , PH. CHANG, TH. LINDER: Meatoplasty for
Lateral StenOSIS of the External Auditory Canal, The
Laryngoscope 112: 1310--1314, 2002
HOUSE WF, HITSELBERGER WE: The transcochlear
approach to the skull base. Arch Otolaryngol: 102: 334-
342,1976
, FISCH U., OEZBILEN G.A., A. HUBER: Malleostapedotomy
in Revision Surgery for Otosclerosis, Otology &
Neurotology, 22:776-785, 2001
HUBER A. , LINDER T. and FISCH U.: Is the Er: Yag Laser
Damaging to Inner Ear Function?, Otology & Neurotology,
22: 311-315, 2001
NANDAPALAN V., POLLAK A., LANGNER A. and FISCH U.:
The Anterior and Superior Malleal Ligaments in
Otosclerosis, Otology & Nerotology, 23: 854 - 861 , 2002
KWOK P. , FISCH U., STRUTZ J. and MAY J.: Stapes
Surgery: How Precisely Do Different Prostheses Attach to
the Long Process of the Incus with Different Instruments
and Different Surgeons?, Otology & Nerotology, 23: 289-
295,2002
HUBER A., KOIKE T., NANDAPALAN V., WADA H. and
FISCH U.: Fixation of the Anterior Mallear Ligament:
Diagnosis and Consequence for Hearing Results in Stapes
Surgery, Annals of Otology, Rhinology & Laryngology, 112:
348 - 355, 2003
FISCH U., MAY J., LINDER TH . and NAUMANN I.C.: A New
L-shaped Titanium Prost hesis for Total Reconst ruction 01
the Ossicular Chain, Otology & Neurotology, 25: 891 - 902 ,
2004
H Prostheses and Instruments
H.1 FISCH Titanium Middle Ear

Prostheses
H.2 FISCH Special Instruments for

Tympanoplasty, Mastoidectomy
and Stapedotomy -
FISCH Special Instruments for Tympanoplasty,

Mastoidectomy and Stapedotomy
Temporal Bone Dissection ~ The Zurich Guidelines 47
ID 220213 FISCH Endaural Retractor @ 226605 FISCH Manual Perforator, 0.5 mm

(j) 219613 Curved Mastoid Retractor @ 226606 FISCH Manual Perforator, 0.6 mm
(BELLUCCI). length 13 cm @ 221 111 FISCH Small Straight Alligator Forceps,
(j) 219717 B FISCH Articulated Retroauricular smooth, (crimping forceps for stapes
Retractor prosthesis)
@ 792003 Strong Curved Scissors (MAYO) @ 221110 FISCH Large Straight Alligator Forceps,
@) 213410 FISCH Small Tympanoplasty Scissors smooth (crimping forceps for stapes
prosthesis)
@ 535312 Small Curved Clamp (Mosquito)
@ 221201 FISCH Small Straight Alligator Forceps,
CD 208000 Scalpel Handle No.3, length 12.5 cm
serrated
® 208001 FISCH Round Scalpel Handle,
length 14 cm @ 221 100 Large Straight Alligator Forceps,
serrated (HARTMANN)
® 211804 FISCH Dual Purpose Scalpel Handle,
@ 221406 F Ultra Fine Biopsy Forceps
length 16 cm
(FISCH, 8 cm, 0.6 mm)
@ 214500 F Jeweler Forceps, soft spring
@ 793303 F Small Tympanoplasty Forceps
0 221409 Small Biopsy Forceps
(\'VULLSTEIN, 8 cm, O.g mm)
(Tissue Forceps), toothed
@ 162020 Large Biopsy Forceps
@ 214000 F Small Tympanoplasty Forceps (HARTMANN, 2.0 mm)
serrated
@ 213011 FISCH Mastoid Raspatory
® 222606 FISCH-BELLUCCI Ultra Fine
Tympanoplasty Micro Scissors
@ 477500 KEY-Raspatory (curved FREER) @ 222603 FISCH Small Tympanoplasty Micro
@ 224003 FISCH Double End Sharp Curette Scis sors
(HOUSE , medium) @ 222601 Large Tympanoplasty Micro Scissors
® 204729 FISCH Suction Tube, 1.2 mm (FISCH-BELLUCCI)
® 204730 FISCH Suction Tube, 1.5 mm ~ 222710 FISCH Crurotomy SCissors, curved right
@ 204732 FISCH Suction Tube, 2.0 mm ® 222720 FISC H Crurotomy SCis sors, curved left
@ 204733 FISCH Suction Tube, 2.2 mm
® 222801 FISCH Malleus Nipper
~ 204352 Suction Cannula, angular,
® 227525 FISCH Cutting Block for Titanium
size 0.7 mm, 7.0 cm Prostheses
@ 204354 Suc tion Cannula, angular.
® 227527 Crimping Forceps,
size 1.0 mm, 7.0 cm for FISCH Titanium Incus Prosthesis
@ 204250 FISCH Suction Adaptor ® 227530 Holding Forceps,
for FISCH Titanium Incus Prosthesis
@ 226101 FISCH Micro Raspatory, curved right
@ 227532 FISCH Micro Hook, for transporting and
@ 226102 FISCH M icro Raspato ry, curved left positioning the FISCH Titanium Incus
@ 226301 FISCH Tenotome Prosthesis
@ 226810 Joint Knife, 45°, round (p 227528 Sc issors,

for FISCH Titanium Total Prosthesis
@ 225405 Pick 45°,16 cm, 0.5 mm
@ 227526 Holding Forceps,
@ 2254 10 Pick 45°, 16em, 1.0 mm for FISCH Titanium Total Prosthesis
@ 225415 Pic k 45°, 16 em, 1.5 mm ~ 227534 Diamond Burr, 1.4 mm, 7 em
® 225425 Pick 45°, 16 em, 2.5 mm
8 843016 Bipolar Coagulating Forceps, angular,
@ 225205 Pick 90°, 16 em, 0.5 mm tip 0.4 mm, insulated, length 16 em
@ 225210 Pick 90°, 16 em. 1.0 mm 6 843016 F Bipolar Coagulating Forceps, angular,
tip 0.2 mm, insulated handle, non-insulat-
@ 225215 Pick 90°,16 em. 1.5 mm ad from angle to tip, length 16 em
@ 225220 Pick 90°,16 em, 2.0 mm ® 842016 F Bipolar Coagulating Forceps,
@ 226514 FISCH Measuring Caliper, 0.4 mm angled tip, pointed , tip 0.4 mm, insulated,
length 16 em (not illustrated)
QII 226516 FISCH Measuring Caliper, 0.6 mm
@ 226501 FISCH Measuring Rod
e 516013 Needle Holder, tungsten carbide
Inserts, length 13 cm
@ 224812 FISCH Anterior Footplate Elevator @ 227900 SHEA Vein Press, 13 em
@ 224813 FISCH Posterior Footplate Elevator e 23 1009 FISCH Glass Cutting Board
® 226600 FISCH Manual Perforator, 0.3 mm ® 239728 Metal Tray, for 20 straight ear micro
@ 226604 FISCH Manual Perforator, 0.4 mm instruments (not illustrated)
220213 219613 219717
CD 220213 FISCH Endaural Retrac tor
<V 219613 Curved Mastoid Retractor (BELLUCCI), length 13 em
@ 219717 B FISCH Artic ulated Retroauricular Retrac tor
792003 213410 535312
o 792003 Strong Curved Scissors (MAYO). length 16 em
® 213410 FISCH Small Tympanoplasty Scissors
@ 535312 Small Curved Clamp (Mosquito)

49
® ®
208000 20800 1 211804
o 208000 Scalpel Handle No, 3. length 12.5 cm
® 208001 FISCH Round Scalpel Handle, length 14 cm
® 211804 FISCH Dual Purpose Scalpel Handle, length 16 cm
® @
2 14500 F 793303 F 214000 F
@l 214500 F Jeweler Forceps, pointed. soft spring
® 793303 F Small Tympano pla sty Fo rceps (Tissue Forceps).

toothed
@ 214000 F Small Tympanoplasty Forceps, serrated

@ @
226101
,
!,
226102
@-@ @-@ @
213011 477500 224003 204729 - 204733 204352 204250 226101-226102

204354
@ 213011 FISCH Mastoid Raspatory, 10 mm
@ 477500 KEY-Raspatory (curved FREER). 18 mm
@ 224003 FISCH Double End Sharp Curette (HOUSE, medium)
@ 204729 FISCH Suction Tube, 1.2 mm

® 204730 Same, 1.5 mm
® 204732 Same, 2.0 mm
@ 204733 Same, 2.2 mm
® 204352 Suction Cannula, angular, size 0.7 mm, 7.0 em

@ 204354 Same, size 1.0 mm. 7.0 em
@ 204250 FISCH Suction Adaptor
13 226101 FISCH Micro Raspatory, 16 em, CUNed right
@ 226102 FISCH Micro Raspatory, 16 em, curved left

Temporal Bone Dissection - The Zuneh GUidelines 51
®-@
,•
226301 226810 225405 - 225425 225205 - 225220
@ 226301 FISCH Teno tome, 16 cm

@ 226810 Joint Knife, 45". round
@ 225405 Pic k 45°, 16 em. 0.5 mm

@ 225410 Pick 45°, 16 em. 1.0 mm
@ 225415 Pic k 45°, 16 em. 1.5 mm
@ 225425 Pic k 45°,16 em, 2.5 mm
® 225205 Pick goo, 16 em, 0.5 mm

@ 225210 Pick 90", 16 em, 1.0 mm
@ 225215 Pick 90°, 16em,l.5mm
@ 225220 Pic k 90",1 6 em, 2.0 mm
226514 226501 224812 226600 - 226606

226516 224813
® 226514 FISC H Measuring Caliper, 0.4 mm

@ 2265 16 Same, 0.6 mm
® 226501 FISCH Measuring Rod, 16.5 em
@ 224812 FISCH Anterior Footplate Elevator, curved upward 90"
@ 224813 FISCH Posterior Footplate Elevator, curved downward 90"
~ 226600 FISCH Manual Perforator, 0.3 mm

@ 226604 Same, 0.4 mm
@ 226605 Same, 0.5 mm
0 226606 Same, 0.6 mm
Temporal Bone Dissect ion - The Zurich GUidelines
,-
221111 2211 10
221201 221100
= - - <--
-, ...
221406 F
221409 162020

smooth, (crimping forceps for stapes prosthesis)
® 221 110 FISCH large Straight Alligator Forceps. smooth

(crimping forceps for stapes prosthesis)

serrated
@ 221100 large Straight Alligator Forceps ,

serrated (HARTMANN), 0.4 x 3.5 mm
@ 221406 F Ultra Fine Biopsy Forceps (FISCH. B cm, 0.6 mm)
® 221409 Small Biopsy Forceps (WULlSTEIN. 0.9 mm)
@ 162020 large Biopsy Forceps (HARTMANN , 2.0 mm)

®"'"'--
222606
•
222710
222603 222720
222603 222710
222606 222720
222601 222801
® 222606 FISCH -BELLUCCI Ultra Fine Tympanoplasty Micro Scissors
~ 222603 FISCH Small Tympanoplasty Micro Scissors
~ 22260 1 large Tympanoplasty Micro Scissors (FISC H-BELLUCCI)
S 222710 FISCH Crurotomy Scissors, curved right

~ 222720 Same, curved left
S 222801 FISCH Malleus Nipper

•
•
@ 227525 FISCH Cutting Block,
lor Titanium Prostheses
227525
227527 227530 227532 227528 227526
@ 227527 Crimping Forceps, for FISCH Titanium Incus Prosthesis
<I} 227530 Holding Forceps, for FISCH Titanium Incus Prosthesis
0 227532 FISCH Micro Hook, for transporting and positioning

the FISCH Titanium Incus Prosthesis
@ 227528 Scissors, for FISCH Titanium Tolal Prosthesiss
@ 227526 Holding Forceps, for FISCH Titanium Total Prosthesis
227900
227534 843016 843016 F 842016 F 516013

231009
0 227534 Diamond Burr, 1.4 mm, 7 cm ,
9 843016 Bipolar Coagulating Forceps, angular, tip 0.4 mm.
insulated, length 16 cm
0 843016 F Bipolar Coagulating Forceps, angular. 0.2 mm, insulated handle,
non-insulated from angle to lip, length 16 cm
0 842016 F Bipolar Coagulating Forceps, angled tip, pointed,
t ip 0.4 mm, insulated, length 16 cm
(l) 516013 Needle Holder, tungsten carbide inserts, length 13 cm
@ 227900 SHEA Vein Press, 13 cm
0 231009 FISCH Glass Cutting Board
FISCH TITANIUM Middle Ear Prostheses
1. 1.
2275 10 FISCH TITANIUM St apes Pist o n, 227515 FISCH TITANIUM Inc us Prosthes is ,
short distance between loop and 3.0 mm (1.31 diam. 2.0 mm),
cylinder, 7.0 x diam. 0.4 mm, normal size, sterile
short size, sterile
227516 FISCH TITANIUM Inc us Prosthesis.
227511 FISCH TITANIUM Stapes Pist o n, 4.0 mm (1.31 dlam. 2.0 mm),
medium distance between loop and long size, sterile
cylinder, dia. 8.5 x dlam. 0.4 mm,
normal size, sterile 227517 FISCH TITANIUM Inc u s Prosthesis ,
5.0 mm (1.31 diam. 2.0 mm),
227512 FISCH TITANIUM Stapes Pist on , extra long size, sterile
long distance between loop and
cylinder, dia. 10.0 x diam. 0.4 mm.
long size, sterile
227520 FISCH TITANIUM To t al Prosthesis , 227522 FISCH TITANIUM Neom alle us

with foot, 10.0 x diam. 0.6 mm, sterile Prosthesis, 5.0 x diam. 1.1 mm,
sterile
Metal Tray for Sterilizing and Storage of Ear Instruments
239728 M etal Tray, for sterilizing and storage of ear

instruments, perforated, bottom part with
holder for 20 straight ear micro instruments
with octagonal handle type 223300, lid with
silicone bridges. external dimensions
(w xd x hl: 285 x 175 x 36 mm
UNIDRIVE ENT
The multifunc tional unit f or ot o rhin o laryngology
Special Features and Specifica tion s
One unit - six functions:

- Shaver system for surgery of the paranasal sinuses and anterior skull base
- INTRA Drill
- Sinus Burr
- Micro Saw
- STAMMBERGER-SACHSE Intranasal Drill
- Dermatome
Two outputs:
Two motor outputs enable to connect two motors simultaneously. For example an
intranasal drill and a paranasal sinus shaver or two INTRA drill hand pieces may be
connected in parallel.
New integrated irrigation and coolant pump:
Absolutely homogenous, micro-processor controlled irrigation rate throughout the
entire irrigation range. Quick and easy connection of the tubing set.
Touch Screen:
Straightforward function selection via touch screen. The unit stores the parameter
values of the function selected during the last operation session.
Optimized user control via touch screen
Operating elements are simple and clear to read due to color display
Irrigator rod included
• Continuously adjustable revolution range
• Maximum number of revolutions and motor torque:
The set parameters are maintained throughout the drilling procedure by the micro-
processor controlled electronic motor.
• Maximum number of revolutions can be preset
• ,.. . model with connections to the KARL STORZ Communication Bus System
UNIDRIVE" ENT
Specifications
Shaver Mode
Operation mode: oscillating
Maximum revolutions (min '): in conjunctiOn with Micro Shaver Handpiece 40 7110 35 3.000
in conjunction with Paranasal Sinus Shaver Handpiece 40 711039 7.000
in conjunction With OriliCut-X Shaver Handpiece 40 711040 7.000
Sinus Burr Mode
Operation mode: rotating
Maximum revolutions (min '): in conjunction with DrillCut-X Shaver Handpiece 40 711 0 40 12.000
Drilling mode
Operation mode: counter clockwise or clockwise
Maximum revolut ions (min '): in conjunction with EG micro motor 20 711032 40.000
Micro saws mode
Maximum revolut ions (min '): in conjunction with EG micro motor 20 711032 20.000
Intranasal Drill mode
Maximum revolutions (min '): in conjunction with EG micro motor 20 711 0 32 60,000
Dermatome mode
Maximum revolutions (min '): in conjunction with EC micro motor 20 711032 8.000
Touch screen: 6.4"/300 cd/m'
Power supply: 100 -120, 230 - 240 VAG, 50/60 Hz
Dimensions (w x h x d): 304 x 164 x 263 mm
Weight: 6.1 kg
Two outputs for parallel

connection of two motors
Integrated irrigation pump
Flow: 15 - 125 ml/min.
Available languages: English, French, German, Spanish, Italian, Portuguese, Greek,

Turkish Certified to: IEC 601-1 CE, according to MOD
20 711 0 72
20 711032
Special feature s of the high performance EC micro motor with INTRA coupling:
• Self-cooling, brushless high

performance EG micro motor
• INTRA coupling enables a wide
variety of appl ications
• Smallest possible dimenSions
• Maximum torque 4 Ncm
• Autoclavable
• Number of revolutions can be
• Detachable connecting cable continuously adjusted from
o - 40,000 rev./mln.
UNIDRIVE ENT
System Configurations recommended by KARL STORZ
B 00
20 711620·'
40 711601-1 UNIDRIVE ENT

consisting o f:
20 711620-1 UNIDRIVE ENT with KARL STORZ-SGB •
100 - 120, 230 - 240 VAC, 50160 Hz
400A Mains Cord
20 012630 Two-Pedal Footswitch, two-stage,
with proportional function
20 711640 Silicone Tubing Set, for irrigation, sieriiizable
20 711621 Clip-Set, for use wit h tubing set 20 711640
20 090 1 70 SGB Connecting Cable, length lOa em
Accessories:
20 711032 High Performance EC Micro M otor
20 711072 Connecting Cable, to connect EC molor 20 7110 32
to control unit
280052 B Universal Sprayer, 0.5 I bottle, for use with 280052 C,
- HAZARDOUS GOODS - UN 1950
260052 C Spray Diffuser, for use with 280052 B
mtp· Set of Tubes, for single patient use
*) This product is marketed by mtp.

For additional information, please apply t o:
~
mtp medical technical promotion g mbh,
p.o. box 4529,78510 Tuttlingen, Germany
Email: info@mt p-tut.de
UNIDRIVE ENT
System Components
Two·p.cjal Footlwltcll
I I
20 711640
STe1'Z -. . • .. ..
U NIT SIDE
---
PATIENT SIDE
B 00
-
20 7Il0:rz
20 1110n
Micro Saw
" 1
- Ei
2f>4000 - 2f>4300 2~-2!;3300

INTRA Drill Handpiece
Special Features:
• Tool-free c losing and opening of the drill • light con struction
• Right/left rotation • Operates with little vibrations
• Max. rotating speed up to 40,000 min ' • low maintenance , easy c leaning
• Detachable irrigation channels • Safe grip
252475
252475 INTRA Drill Handpiece, angled , 12.5 em, for use with
straight shaft burrs, transmission 1:1 (40,000 rpm)
252495
252495 INTRA Orill Handpiece, straight, long shape, 10.4 em, for
use with straight shaft burrs, transmission 1: 1 (40,000 rpm)
252490
252490 INTRA Drill Handpiece, st raight, 8.7 em, for use with
straight shaft burrs, transmission 1:1 (40,000 rpm)
280052
280052 Universal Spray, combination cleaner and lubricant , for INTRA Drill
Handpiece and EC motors, package of 6 sprayers 280052 Band
1 spray d iffuser 280052 C - HAZARDOUS GOOD - UN 1950
Burrs
Straight Shaft Burrs, length 7 em
7.0 em
Tungsten Transverse Diamond

Size Dia. mm Standard Diamond
Carbide Tungst.Carb. coarse
006 0.6 260006 261006 262006
007 0.7 260007 262007
008 0.8 260008 261008 262008
010 1.0 260010 261010 262010
014 1.4 260014 261014 261114 262014
018 1.8 260018 261018 262018
023 2.3 260023 261023 261123 262023 262223
027 2.7 260027 261027 262027 262227
031 3.1 260031 261031 261131 262031 262231
035 3.5 260035 261035 262035 262235
040 4.0 260040 261040 261140 262040 262240
045 4.5 260045 261045 262045 262245
050 5.0 260050 26 1050 261150 262050 262250
060 6.0 260060 261060 261160 262060 262260
070 7.0 260070 261070 262070 262270
260000 Standard Straight Shaft Burrs,

length 7 em, sizes 006 - 070, set of 15
261000 Tungsten Carbide Shaft Burrs,

262000 Diamond Straight Shaft Burrs, with smooth shaft,

262200 Rapid Diamond Straight Shaft Burrs, with coarse

diamond coating for precise drilling and abrasion by light
hand pressure. generating minimal heat. length 7 em,
sizes 023 - 070, set of 9
280030 Rac k, for 36 straight shaft burrs with a length of 7 em,

can be folded out, sterilizable. 22 x 11.5 x 2 em
Burrs
Straight Shaft Burrs, length 5.7 em
5.7 em
Size
e=
Dia. mm Standard Diamond
Diamond
coarse
0 014 1.4 649614 K 649714 K
(0 018 1.8 649618 K 649718 K
0 023 2.3 649623 K 649723K 649723 GK
027 2.7 649627 K 649727 K 649727 GK

0
031 3.1 649631 K 649731 K 649731 GK
0
649735 GK
0 035 3.5 649635 K 649735 K
0 040 4.0 649640 K 649740 K 649740 GK
0 045 4.5 649645 K 649745 K 649745 GK
0 050 5.0 649650 K 649750 K 649750 GK
0 060 6.0 649660 K 649760 K 649760 GK
0 070 7.0 649670 K 649770 K 649770 GK
649600 K Standard Straight Shaft Burrs,

stainless steel. length 5.7 em, sizes 014 - 070,
setof11
649700 K Diamond Straight Shaft Burrs,

stainless steel , lengt h 5.7 em. sizes 014 - 070,
set of 11
649700 GK Rapid Diamond Straight Shaft Burr, stainless,

with coarse diamond coaling for precise drilling
and grinding without applying pressure with
minimal heat buildup. length 5.7 em,
sizes 023 - 070, set of 9
Straight Shaft Burrs

oblong, length 1 em 265050 - 265070
Size Oia. mm Standard
050 5.0 265050
060 6.0 265060
070 7.0 265070

Burrs
LINDEMANN Conical, stainless,

length 7 em
Size Dia. mm Standard
018 1.8 263518

021 2.1 263521
023 2.3 263523
Diamond Straight Shaft Saw,

length 7 em
Size Oia. mm Standard

008 0.8 267008
010 1.0 267010
015 1.5 267015
Diamond Saw Crill,

length 7 cm
Size Dia. mm Standard

008 0.8 268008
010 1.0 268010
015 1.5 268015
269000
- ... .... II " " " •• ~ &:)~

- .. , - '" .. .... on ... . . , _ _ _ _ _ ...
280090
280090 Hole Gauge, for burrs, stainless,

autoclavable
Burrs - Accessories
280010 Rac k , with lid for 34 straight shaft burrs with 7 em shafts, sterilizable,
19.5x 9.5 x4 em
280080 280120
280080 Brush, for cleaning burrs, sterilizable, package of 5
280120 Temporal Bone Holder, bowl-shaped, with 3 fixat ion screws for tensioning
the petrosal bone and wit h evacuation tube for irrigation liquid, incl. weight
plate 280121 for stabilization of the bowl and rubber ring 8575 GKR for
base to prevent sl ipping
280030
280030 K
280030 Rack, for 36 st raight shaft burrs with a lengt h of 7 em.

can be folded Qut , sterilizable, 22 x 11.5 x 2 em
280030 K Metal bar, for fixation at rack 280030.
to hold 18 burrs with a lengt h of 7 em and 16 burrs
with a length of 5.7 em, size 16 x 2.5 x 1 em
Burrs - Accessories
39552 A
•
. • ••
' •
•
. ..
: ..:
Including basket for small parts
39552 A Sterilizin g a nd Sto rage Basket , provides safe storage of accessories for
KARL STORZ drilling/grinding systems during cleaning and sterilization,
Includes basket for small parts, for use with rack 280030, rack not included
f o r st ora ge of:
- Up to 6 drill handpieces
- Connecting cable
- EC micro motor
- Small parts
39552 B St erilizin g and Sto rage Bas ket, provides safe storage of accessories for
KARL STORZ drilling/grinding systems during cleaning and sterilization,
Includes basket for small parts, for use wi th rack 280030, rack inc luded
fo r stora ge of:
- Up to 6 drill hand pieces
- Connecting cable
- EC micro motor
- Up to 36 drill bits and burrs
- Small parts

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In collaboralion wilh

Deparlment ot ENT, Lucerne Cantonal Hospital, Switzerland

Prof. Ugo FISCH, M.D.

This booklet is based on teaching material distributed at

We are grateful to the follow ing persons,

Prof. John May, M.D.

Prof. Rodrigo Posada, M.D.

FISCH INTERNATIONAL MICROSURGERY FOUNDATION

Illustrations by: Temporal Bone Dissection - The Zurich Guidelines

C 20Cl6 Endo-Press "'. Tutthngen, Geliliany

Edit ions in other languages than English and German are in

Typesetting and Image Processing:

A.2 General Preparation ............. . . . . . ... .. . . . .. ... . .... . . . ....... . .... 6

A.3 Specific Surgical Techniques ...... . .. . . . . .. . . . .. . . .. . . . ...... . . . . .. ... • 7

B Closed-Cavity Technique .... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

o Open Cavity Techniques (Mastoido-Epitympanectomy, Open MET)

E Tympanoplasty (Myringoplasty and Ossiculoplasty) in Open Cavities .........• 35

F Additional Temporal Bone Dissections

H Prostheses and Instruments

H.l FISCH Titanium Middle Ear Prostheses. . . . . . . . . . . . . • . . . . . . . . . . • . . . • . . 45

6 Temporal Bone Dissection - The Zurich Guidelines

A.1 Introduction A.2 General Preparation

Identify the following anatomical landmarks (Fig. 1):

A.3 Specific Surgical Techniques

The steps of this operation are: , '..,..

Meatoplasty is a necessary step in addition to canalplasty

Elevation of the laterally Based Skin Flap

Excess of bone behind

Exposure and Excision of Conchal Cartilage

• kept in position with 4-0 Et hibond sutures (Fig. 9). The

Exposure of the EAC

Meatal Skin Flap

Incisions for the Meatal Skin Flap

Elevation of Meatal Skin Flap from the Tympanic Bone

TymparlO- Exposed lateral

Separation of the skin covering the posterior surface of the

Middle Ear Inspection and Preparation

Freshening the Perforation Margins

Inspection of the Ossicular Chain

Temporal Bone Dissection - The Zurich Guidelines 15

Fixation Points for Underlay Grafting

CD On the ledge of the new anlero-inferior tympanic sUl- •

The anlrotomy is carried out when the function of the

Water Test for Epitympanic Patency

8 .1.6 Transmastoid Drainage

After exposmg the antrum, a groove is drilled posteriorty

The sleps required for a closed Mastoido-Epitympanec-

Meatoplasty, Ganalplasty. Epltympanectomy, Mastoidec-

Some of these surgical steps are the same as for retroau-

Ide ntification of the Fac ial Nerve (Fig. 31)

• Enlarge the antrotomy superiorly by skeletonizing the

B.2.2 Posterior Tympanotomy

With the facial nef'Ve in view, the facial recess can be

• stapes and stapedial tendon

The incudo-stapeclial joint is separated , and the incus is

B.3 Myringo- and Ossiculoplasty

General Con sideratio ns

8 .3.2.1 Incus Interposition

8 .3.2.2 Autologous Incus

In the presence of intact stapes, malleus handle and ante-

Measuring the Length and Angle of the Implant

Shaping the Autologous Incus

Interposition of the Modified Autologous Incus