Figs 1.1A to C: Child with congenital deformity of both ears—microtia. He has severe conductive deafness which has to be corrected quickly as the condition is bilateral. The plastic surgery of the pinna though insisted on by the parents has to wait till growth of facial skeleton is complete. The hearing loss is managed by bone-anchored hearing aid (BAHA) or bone conduction hearing aid by means of a pressure strap or by microsurgical correction of the middle ear. In such cases, apart from the middle ear ossicles facial nerve anomalies are common and surgeon should procure high resolution CT scan of temporal bone and should have skill in fashioning and fixing middle ear implants for surgical correction. Most common defects we have seen in such cases are the loss of long process of incus, fixed incudomalleal joint and monocrural stapes with mobile/fixed footplate. Low hanging facial nerve obscuring footplate was seen in all our cases. We prefer a Teflon wire prosthesis made on the table to connect the incus stump to the fenestra drilled below the footplate
Figs 1.2A and B: 3D reconstruction with color rendition of a congenitally deformed middle ear with incus long process loss and IM joint fixation
Figs 1.3A and B: HRCT of the temporal bone of the same case. Please note the fixed incudomalleal joint in the attic. The second cut shows measurement of thickness of squamous temporal bone. We need it to be above 4 mm for fixing the bone-anchored hearing aid (BAHA) which is currently the best option for such cases. This also means that the child should be above 5 years age for this thickness of bone to develop
Fig. 1.4: Diabetic malignant external otitis with thin serous ear discharge. Pseudomonas is the usual organism grown. Apart from suitable IV antibiotics, 2% acetic acid eardrops is of proven value. Acidic pH reduces multiplication of this usually multidrug-resistant bacteria
Fig. 1.5: Facial paralysis of LMN type seen in the same patient. Always assess the taste in anterior 3rd of tongue to ascertain the level of lesion above or below the chorda tympani nerve
Figs 1.7A and B: CT scans of the same patient. Bone details are shown better in a CT and soft tissue details in a MRI. Combination of both is required in assessment of temporal bone pathologies spreading to the soft tissues of the intracranial space and also in planning for cochlear implants
Fig. 1.8: Keloid of the ear lobe after ear piercing. The lesion will recur if excised and we manage them by repeated intralesional injections of depot steroids and hyalase combination
Fig. 1.9: Burn wound of the pinna caused by cellphone which was being used while it was charging. The electrical problems in the A/C mains led the cell phone to partially explode resulting in this injury. Apart from the wound the patient also developed moderately severe sensorineural hearing loss
Fig. 1.10: Insulin-dependent diabetes with malignant external otitis left ear. Please note the left facial LMN type palsy and fullness of left infratemporal fossa. This results from contiguous spread of inflammatory process to temporomandibular joint, parotid and infratemporal areas. The condition requires debridement of necrotic mastoid bone and soft tissues followed by IV antibiotics for 30 to 45 days with diabetic control
Figs 1.11A and B: HRCT temporal bone in diabetic malignant otitis with bone destruction from the pathology starting in the external auditory canal. Caused by pseudomonas, antimicrobial therapy is the mainstay of treatment by using IV antibiotics and topical 2% acetic acid drops. MRI shows the intracranial destruction in the same patient
Figs 1.12A and B: CT scan in a young adult with unilateral sensory neural loss of recent onset. Audiologically dead ear with arachnoid cyst compressing pons and medulla. He was operated with relief of compression but the deafness will remain. In conditions like bilateral acoustic neuroma and type 2 neurofibromatosis, a brainstem hearing implant is indicated
Fig. 1.13: Cochlear implant. The implant is placed too close to the pinna and can lead to fitting problems for behind the ear type processors. The implant is ideally kept away from the pinna and away from the skin incision
Figs 1.14A and B: Cochlear implantee with infection. Postoperative complication rate after cochlear implant is about 6%. Postoperative infection can be immediate or delayed as in this case. Once a portion of implant is engulfed by infection and biofilm formation slow extrusion takes place as in this case. This child was reoperated with a new implant and is doing well
Fig. 1.15: Donor site of split skin grafts taken for tympanoplasty. When the skin is harvested with microdermatome, the site heals in 10 days
Fig. 1.16: Uninfected preauricular sinus with discharge of pultaceous debris on pressure over sac area. As long as, this material is constantly evacuated periodically, the black head formation and secondary obstruction does not occur. Once obstructed and infected, the primary drainage through natural punctum dilatation should be tried and I and D of the abscess has to be kept as the last resort
Fig. 1.17: MRI showing right-sided acoustic neuroma in a patient with unilateral sensorineural hearing loss of less than one year duration. Such patients undergo audiological tests to determine the level of lesion of the involved 8th cranial nerve. These tests include stapedial reflex decay, speech reception thresholds (very poor in retrocochlear deafness), OAE, and caloric testing. In the present days, tumors like this of less than 3 cm diameter are approached by translabyrinthine route with very good rates of preservation of facial nerve
Fig. 1.18: MRI brain showing bilateral acoustic neuromas in a case of NF type 2. Following their excision brainstem auditory implant has to be used to restore hearing
Fig. 1.19: 7th postoperative day after cochlear implantation. A small incision for minimal access technique and the wound heals well so that the implant is switched-on on the 8th postoperative day
Fig. 1.20: Postoperative X-ray of a cochlear implant (cochlear view) shows the electrodes going into the turns of the cochlea. Such as X-ray is taken immediately after operation to ensure correct placement of these expensive devices
Fig. 1.22: Nucleus implant is tied down into the well made in the skull with woven Teflon tape. Such fixations are required to prevent implant migration
Fig. 1.23: HRCT temporal bone axial cut showing the typical “icecream cone” appearance of malleus and incus in the attic
Fig. 1.24: HRCT inner ear showing the cochlear duct. This should be free to allow passage of the electrode array of the cochlear implant. In purulent meningitis the inner ears shut down and new bone formation obstructs the cochlea in about 3 months. Hence, postpurulent meningitic children with sensory deafness should have hearing restored within 3 months to prevent the labyrnthitis ossificans contraindicating implant placement where the family cannot afford an implant, the cochlea can be stented by a dummy electrode array of suitable thickness to allow space formation so that in future the ear can be implant
Fig. 1.25: MRI of temporal bones in a child planned for cochlear implant showing enlarged vestibular aqueduct. Such patients may develop endolymphatic gusher during cochleostomy and require advance planning. This is not an absolute contraindication for CI
Fig. 1.26: X-ray mastoid showing erosion and air shadow in the tegmen antri in a case of encephalocele
Fig. 1.27: 7 month old infant with external, middle and inner ear malformation. In such cases, priority goes to hearing restoration in bilateral cases. However, parental demand is for pinna reconstruction which has to wait till growth is complete
Figs 1.28A and D: Left temporal bone HRCT showing atresia, deformed single ossicular bone, middle ear hypoplasia, nonpneumatized mastoid and proximal tympanic segment of VII nerve with a vertical course after the first genu and not beneath LSCC
Figs 1.29A and C: Osteoma of external auditory canal may be caused by frequent entry of cold water in the canal. The lesion in this case was removed in toto with microscopic guidance
Figs 1.30A to C: Facial nerve neuroma in the horizontal segment of facial canal. Patient presented with mild facial paresis of 2 months duration. The lesion would have been missed if the HRCT was not done. A simple CT scan of head would have also missed it. Given the partial paresis situation, it was decided to wait and surprisingly after 1 year patient fully recovered and repeat scan showed that the lesion had disappeared. Possibly, the original pathology was only a granuloma which got resolved. The patient is still under follow-up after 4 years.
Fig. 1.31: Bone-anchored hearing aid (BAHA) soon after implantation of the titanium screw (post). This is placed into the skull bone and undergoes a process called osseointegration. On this post, the receiver stimulator is placed which conveys sound directly to inner ear via the bone in conditions like gross middle ear congenital deformity unsuitable/risky for middle ear microsurgical correction. Costing half of a cochlear implant, this treatment has become mainstay in congenital external and middle ear deformity. In our practice, one out of 4 patients opt for this and the others are subjected to middle ear reconstruction using custom-made Teflon wire prosthesis
Fig. 1.33: One of the most common causes for pain and discomfort after mastoidectomy is the reluctance of patients to clean the postaural wound area. Once debris accumulates as in this case it leads to local inflammation and pain which disappears on proper care
Figs 1.34A and B: Clinical appearance of mastoid abscess. Irregular erosion of mastoid cortex seen during surgery is typical of cholesteatoma induced mastoid abscess
Fig. 1.35: Tympanic membrane with a hair lice on the lateral process of malleus. The lice is one of the reasons for repeated activity of CSOM in long hair patients with poor scalp hygiene. In postoperative period such infestations lead to infections and on culture Staphylococcus is grown. One should always clear these before taking up the patient for otologic surgery
Figs 1.36A and B: Patients with cochlear implants. (A) shows a postaural speech processor with the magnetic tele coil hidden in the hair. (B) shows the magnetic telecoil connected with a body worn speech processor kept under clothing. The connecting wire is cleverly kept invisible
Fig. 1.37: Facial paralysis with herpetiform eruptions in the well of the concha leading to a diagnosis of herpes zoster oticus. Caused by varicella zoster virus the condition is treated by the antiviral agent zovirax
Fig. 1.38: Normal X-ray of the mastoid with good pneumatization and intact tegmen, normal position of sinus plate
Fig. 1.39: Operated mastoid with cavity seen in the X-ray. The margins are clear and definitive unlike cavity caused by disease
