GENERAL PROCEDURES AND TREATMENT MODALITIES

Ear Surgery
Ear surgery may involve the tympanic membrane, the middle ear cavity, the mastoid, or the inner ear. It
may be done for perforation of the eardrum to facilitate drainage and remove diseased tissue in cases of
infection or cholesteotoma, to relieve vertigo, or to treat hearing loss.

Types of Surgery
1. Myringotomy—creating a surgical opening into tympanic membrane (with knife or laser) for
possible drainage tube insertion.
2. Tympanoplasty—reconstruction of diseased or deformed middle ear components
a. Type I (myringoplasty)—purpose is to close perforation by placing a graft over it to create a
closed middle ear to improve hearing and decrease risk of infection and cholesteatoma. Perforation
is closed using one of the following:
i. Fascia from temporalis muscle (this is the most commonly used material).
ii. Vein grafts from hand or forearm.
iii. Epithelium from auditory canal (eustachian tube).
b. Type II to V—suitable replacement (polyethylene, Teflon or titanium prosthesis, bone, cartilage)
is used to maintain continuity of conduction sound pathway. The necessity of a two-stage
procedure is determined.
i. First stage—eradication of all diseased tissues; area is cleaned out to achieve a dry,
healed middle ear.
ii. Second stage—performed 4 to 6 months after first stage; reconstruction, using grafts.

3. Mastoidectomy—removal of mastoid process of temporal bone.

a. Simple or cortical mastoidectomy is done via a postauricular approach but the bony ear
canal is left intact.
b. Modified radical mastoidectomy or canal wall down mastoidectomy is done with a
meatoplasty for the best results. A wide excision of the mastoid and diseased middle ear
contents through a postauricular incision is performed with the bony canal being drilled out.
 A new larger ear canal is created that gives better access to the areas where
cholesteatoma usually occurs (the attic and antrum).
4. Stapedectomy—removal of footplate of stapes and insertion of a graft or prosthesis
5. Stapedotomy—removal of the stapes suprastructure, allowing a hole to be created with a laser in
the stapes footplate. The base of the prosthesis will be inserted into the opening and the other end
will be crimped around the incus.
6. Labyrinthectomy—destruction of the labyrinth (inner ear) through the middle ear and aspiration of
the endolabyrinth.
7. Endolymphatic decompression and shunt—release of pressure on the endolymphatic system in the
labyrinth and creation of a shunt for fluid to the subarachnoid space or the mastoid.
8. Cochlear implant—implantation of electronic device that bypasses the damaged cochlea and
stimulates auditory nerve.
9. Osseointegrated implantation for placement of a hearing implant for single-sided deafness or for
conductive hearing loss (Baha system or Oticon implantable hearing system).

Preoperative Management
1. Hearing function is fully evaluated.
2. Antibiotics are given to treat infection.
3. The patient is prepared emotionally for the effects of surgery.
4. Careful assessment for signs of acute infection is performed, which may delay surgery.

Postoperative Management
1. Antibiotics may be continued to prevent local and central nervous system (CNS) infection.
2. Patients are advised to have limited activity for the first 24 hours to decrease symptoms of nausea
and vertigo (if the inner ear was disturbed) or to prevent disruption of prosthesis.
3. Analgesics, anti-emetics, and antihistamines are given, as needed.
4. The patient is positioned to promote drainage but maintain some immobility. Using two extra
pillows to elevate the head, thereby preventing edema for 2 weeks, is a good idea.
5. Patient is often seen 7 to 10 days after surgery to remove any metal stent placed. Additional
packing may be removed up to
1. 6 weeks postoperatively if prosthesis or graft procedure was performed. Often an ear drop will be
used to slowly dissolve remaining packing over a period of 6 to 8 weeks to give some weight to the
grafted tympanic membrane.
6. Hearing will be reevaluated after edema has subsided and healing has occurred. The time frame
for this varies by procedure but may be as long as 3 to 4 months after surgery to allow for healing.
7. With an osseointegrated implant, a fitting of the outer processor is usually delayed by 2 to 3
months to allow the bone to osseointegrate around the implant. In children, or in radiated bone, this
may be done in two stages separated by 6 months to allow for a slower rate of bone growth.
8. Cochlear implant activation and placement of the outer speech processor and external transmitter
occurs approximately 4 weeks after surgery to allow for healing.

Complications
1. Infection: local, CNS (meningitis, brain abscess).
2. Hearing loss.
3. Facial nerve paralysis—rare.
4. Dizziness—usually temporary.
Nursing Diagnoses
 Acute Pain related to surgical incision and swelling.
 Risk for Infection related to invasive procedure.
 Risk for Injury related to vertigo.

Nursing Interventions
Relieving Pain
1. Administer or teach self-administration of analgesic, as indicated, postoperatively.
2. Tell the patient to expect pain to subside within first few hours with simple procedures or within first
day or two with major procedures.
3. Position the patient for comfort following the instructions from the surgeon.
a. On side with surgical ear upward to maintain graft position and immobility.
b. Lying on side with surgical ear down to promote drainage from ear canal.
c. Position of patient preference.
4. Elevate the head of bed to reduce swelling and pressure.
5. Advise the patient to avoid sudden movement. Use pillows for support.

Preventing Infection
1. Reinforce external dressings, as needed, until after first changed by surgeon, then change when
saturated to prevent bacterial growth in damp dressings.
2. Loosely pack cotton or gauze in ear canal, as indicated, without causing increased pressure.
3. Do not probe or insert anything into ear canal.
4. Administer or teach self-administration of antibiotics, as prescribed. Do not use eardrops unless
specifically ordered postoperatively.
5. Wash hands before ear care and instruct the patient not to touch ear.
6. Take care not to get the dressing or ear wet.
7. Advise the patient not to blow nose, which could cause nasopharyngeal secretions to be forced up
eustachian tube into middle ear.
8. Instruct the patient to report any increased pain, fever, ear inflammation, or drainage, indicating
local infection.
9. Be alert for headache, fever, stiff neck, or altered level of consciousness, which may indicate CNS
infection.

Ensuring Safety
1. Be aware that dizziness or vertigo may occur for the first several days postoperatively.
2. Maintain side rails up while the patient is in bed.
3. Assist the patient with ambulation for the first time after surgery and as needed thereafter.
4. Encourage the patient to move slowly because sudden movements may exacerbate vertigo.
5. Administer or teach self-administration of anti-emetics and antihistamines, as ordered and as
needed; watch for sedation.
6. Instruct the patient not to blow nose, cough, lean forward, or perform Valsalva’s maneuver to avoid
disrupting graft or prosthesis, aggravating vertigo, or forcing bacteria up the eustachian tube. If
coughing or blowing nose is necessary, do so with open mouth to relieve pressure.
Patient Education and Health Maintenance
1. Advise the patient that there may be a temporary hearing loss for a few weeks after surgery
because of tissue edema, packing, and so forth. The effects of a hearing restoration operation will
not be known for several weeks and additional rehabilitation may be necessary to optimize results.
2. Advise the patient to protect the ear, perform dressing changes, or place loose cotton in outer ear,
as indicated. Replace cotton twice daily or sooner if saturated by drainage.
3. Encourage follow-up for packing removal, as directed.
4. Instruct the patient to avoid sudden pressure changes in the ear.
a. Do not blow nose.
b. Do not fly in a small plane. The date for which a patient may fly is individualized by their
surgery and surgeon’s preference.
c. Do not dive.
6. Advise against smoking.
7. Tell the patient to protect ears when going outdoors for the first week. A cotton ball is all that is
needed.
8. Tell the patient to avoid getting ear wet until completely healed.
9. Tell the patient to avoid crowds or exposure to colds so upper respiratory infection is prevented.
10. Instruct the patient about signs and symptoms of complications to report.
a. Return of tinnitus.
b. Vertigo.
c. Fluctuations of hearing ability.
d. Fever, headache, ear inflammation, increased pain, stiff neck.
e. Facial drooping or numbness.
11. Advise the patient that facial nerve paralysis may be temporary and to increase fluid intake through
a straw during this time.

Evaluation: Expected Outcomes

 Verbalizes relief of pain.
 No signs of infection.
 Ambulates without difficulty.