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Education – Video Archive Of Surgical Procedures
1 - External Auditory Canal
1.1 - Acquired Meatal Atresia, R ear canal
Acquired Meatal atresia secondary to chronic myringitis. Repair with bony canalplasty, meatoplasty, and split skin grafts to ear canal and surface of drum, right ear. With English audio description.
1.2 - Ear canalplasty for osteoradionecrosis, with postaural island skin flap to ear canal
Necrotic bone in posterior wall and floor of left ear canal removed. Viable skin cover to line canal obtained by random pattern island of postaural skin on inferiorly based subcutaneous soft tissue pedicle.
1.3 - Cholesteatoma of the Ear Canal, 80y Male
This elderly man has irritation and discharge form his ear due to a skin erosion in the floor of his ear canal. This is called Cholesteatoma of the ear canal, and is distinct from booth middle ear and mastoid forms of cholesteatoma. Through the ear canal the diseased area of skin and bone is removed and grafted.
2 - Meatus
2.1 - M flap type Meatoplasty, Prof Thomas Linder, Switzerland 2020
Professor Linder demonstrates a technique for ear meatoplasty
2.2 - Meatoplasty method, Alexander Uppheim, Tromso, Norway, 2020
Professor Uppheim demonstrates a technique for meatoplasty, with subtitles.
2.3 - Concho-meatoplasty for narrow ear meatus and canal
This right ear has a very narrow external auditory meatus and external auditory canal, secondary to recurrent episodes of otitis externa. Both are widened via a conchal bowl incision.
3 - Ventilation Tubes/Grommets
3.1 -Myringotomy and Titanium Grommet insertion
Adult patient with serous middle ear effusion in left ear. Drum has thin section from an old healed perforation. Grommet ventilation tube placed in a thicker pat of the tympanic membrane.
3.2 - Myringotomies, Glue ear, Shah Grommets and T-tubes
Two patients for bilateral ventilation tube insertion for Glue ear. First has Shah teflon grommets and second, with chronic recurrent middle ear effusion problem (glue), has longer stay T Tubes inserted.
4 - Myringoplasty
4.1 - ‘Butterfly’ myringoplasty, tympanic membrane graft technique, 6 cases
6 cases, with slight variations. A disc of cartilage and perichondrium is removed from the tragus. The graft is taken percutaneously with a skin biopsy punch. The graft is deeply scored around the perimeter, and inserted to fit into the perforation of the ear drum. A relatively simple and quick technique suitable for certain small perforations of the tympanic membrane. 6 cases are shown consecutively with tips about indications and technique. Mike Smith, with audio descriptions.
4.2 - Myringoplasty, microscopic, postaural approach, with underlay temporalis fascia and cartilage ‘petals’
Myringoplasty for perforated ear drum. Right ear, by postaural approach, using microscope. Tympanic membrane grafted with underlay temporalis fascia and cartilage ‘petals’. Mike Smith, with audio description.
4.3 - Myringoplasty using a tragal cartilage and perichondrium island graft
Permeatal, microscopic approach. Underlay graft myringoplasty using a tragal cartilage and perichondrium hinged island graft. Right ear. With English audio description. Mike Smith
4.4 -Tympanoplasty and canal-plasty, underlay grafts, thick middle ear mucosa
Fairly small poster-inferior perforated pocket of ear drum, with extensive polypoid mucosa in middle ear. Bony canal widened and underlay temporals fascia and cartilage grafts placed
4.5 Tympanoplasty, canalplasty, RW reflex, anterior tunnel
Large dry perforation of right ear drum. repaired by post auricular incision, underlay Temporalis Fascia, pulled up anteriorly under annulus with tunnel/buttonhole, and underlay cartilage grafts. The round window reflex is well visualised when checking the mobility of the ossicular chain.
5 - Tympanoplasty +/- Ossiculoplasty
5.1 - Atticotomy with tympanoplasty, and titanium ossiculoplasty with TORP, Tympanosclerosis of stapes
Atticotomy, tympanoplasty, ossiculoplasty using Kurz titanium 'aerial' Total Ossicular Replacement Prosthesis (TORP). Tympanosclerosis fixing stapes removed. Underlay temporalis fascia and cartilage reconstruction of drum. No audio, with subtitles
5.2 - Tympanoplasty, Subtotal perforation, Cortical mastoidectomy, Tympanosclerosis of footplate of stapes, Titanium TORP
Repair of subtotal perforation of right tympanic membrane with temporalis fascia and cartilage, using underlay and anterior tunnel technique. Remove tympanosclerosis of footplate and fit titanium TORP ossicular prosthesis. With English audio description, Mike Smith
5.3 - Tympanoplasty and Applebaum ossiculoplasty
Large wet perforation of right ear drum was repaired with underlay temporalis fascia graft and cartilage. Graft is pulled up through an anterior canal tunnel (buttonhole). The weak thin ISJ is repaired with a small Applebaum H/A prosthesis placed between the short LPI and the stapes head. Mike C F Smith, with audio description
5.4 - Ossiculoplasty, titanium clip PORP
Indication for ear surgery: Severe conductive hearing loss
Findings: Normal ear drum. Malleus and Incus bones fixed to bone wall middle ear in attic.
Procedure: Permeatal microscopic approach. Tympanic membrane elevated. Ossicular fixation identified. Long process of incus and handle of malleus divided. Titanium ‘Clip’ prosthesis placed from stapes to tympanic membrane, with cartilage cover. Mike Smith, with audio.
5.5 - Tympanosclerosis, fixed ossicles, titanium TORP, Tympanoplasty, 10 minutes duration
Findings: Large perforation of drum, with dense tympanosclerosis of drum and around fixed ossicular chain, right ear.
Procedure: Canalplasty, small Atticotomy, clear plaques from drum, attic, off horizontal VII and from oval window. Aerial type Kurz titanium Total Ossicular Replacement Prosthesis (TORP) placed through stapes arch on to mobile footplate. Tympanoplasty using underlay Temporalis Fascia and thin cartilage slices, to repair drum and to reconstruct outer attic wall.
5.6 - Permeatal ossiculoplasty, absent LPI, Kurz titanium clip PORP
Conductive hearing loss due to erosion of the long process of incus and poor contact with the stapes bone. Repaired using a'clip' titanium Kurz partial ossicular replacement prosthesis (PORP), and cartilage graft.
5.7 - Tympanoplasty and Incus interposition ossiculoplasty, for small cholesteatoma adherent to stapes
A retraction pocket arising in the posterior part of the tympanic membrane is stuck to an eroded long process of the incus and to the crura of the stapes, even passing through the arch of the stapes. The pocket also extends into the facial recess and Sinus Tympani. By a postaural approach, with microscope, the drum is elevated and the pocket dissected. In the absence of an endoscope, the ST and stapes are checked with a micro-mirror. The incus is shaped and fitted as an interposition from stapes head to malleus handle. Drum repaired with underlay temporalis fascia and cartilage.
5.8 - Cortical bone Graft TORP ossiculoplasty
In absence of residual ossicles to use for hearing reconstruction, cortical bone may be used. Whilst the trend is to use artificial materials such as titanium or hydroxy-apatite 'out of the box', cortical bone has the advantages of being free and very unlikely to extrude over time. In resource constrained environments this may be particularly useful.
6 - Atticotomy/Attico-Antrostomy
6.1 - Atelectasis, tympanoplasty, ossiculoplasty, incus to fp, exposed horizontal VII
Findings: Atelectatic ear drum with wet postero-superior retraction pocket. Long process of Incus and stapes superstructure eroded, glue in anterior middle ear. Exposed horizontal VII. Procedure: Postaural incision, canalplasty and small posterior atticotomy. Excise retraction pocket. Incus removed, reshaped and placed as TORP, from malleus handle to stapes footplate. Underlay temporalis fascia and cartilage sheets. T ventilation tube placed through cartilage. Mike C F Smith, with audio description.
6.2 - Attico-Antrostomy, Tympanoplasty, Ossiculoplasty with ceramic PORP, lateral canal bony fistula, cavity obliteration
Description; Attico-Antrostomy for cholesteatoma. Ossiculoplasty, Ceravital glass-ceramic prosthesis. Tympanoplasty with temporalis fascia and cartilage. Cholesteatoma removed from bony fistula of lateral semi-circular canal and slightly exposed facial nerve. Mastoid cavity obliteration with bone pate, cartilage and muscle flap. Mike Smith, with audio
6.3 - Anterior drum cholesteatoma, incus interposition ossiculoplasty
Cholesteatoma arising from retraction of anterior tympanic membrane. Atticotomy, Incus interposition Ossiculoplasty, Tympanoplasty, Triune ventilation tube.
6.4 - Canal Wall Down, front to back mastoidectomy, tympanoplasty, t-tube, cartilage to stapes head
Surgical video of removal of an attic and antral cholesteatoma, with reconstruction of the ear drum and obliteration of the mastoid cavity. Surgeon Mike Smith.
7 - Mastoidectomy
7.1 - CAT, small cholesteatoma, incus ossiculoplasty to footplate, laser
A Combined Approach Tympanoplasty (CAT) in a child with low dura and anteriorly placed sigmoid sinus. Right ear. Indication: cholesteatoma arising from a postero-superior retraction pocket of ear drum. Procedure: Tympanoplasty using temporalis fascia and cartilage. Ossiculoplasty using autograft incus placed with short process on stapes footplate and body under malleus neck. KTP laser used to remove diseased stapes crura and to paint affected surfaces in attic and antrum. Mike Smith, with English language audio description
7.2 - MRM, exposed horizontal VII, titanium 'frisbee' ossiculoplasty, cavity obliteration
Modified Radical Mastoidectomy (MRM) / wide Attico-Antrostomy, with cholesteatoma sac dissected off exposed horizontal facial nerve, drum reconstruction with temporalis fascia and cartilage, ossicular reconstruction with titanium ‘Frisbee’ style PORP, cavity obliteration with bone pate and cartilage. Mike Smith, with audio description
7.3 MRM, cavity obliteration, titanium hand made wire TORP, herniated facial nerve
Modified Radical Mastoidectomy for cholesteatoma. including ossiculoplasty using a novel low cost titanium wire Total Ossicular Replacement Prosthesis (TORP). The bony canal of the horizontal segment of the facial nerve in the middle ear was dehiscent, and the nerve was herniating through this and partly obscuring the oval window and stapes footplate. the mastoid cavity as partially obliterated with bone dust and cartilage grafts.
7.4, Seven Mastoid Cavity Obliterations and Ossiculoplasties
Seven cases, ranging from atticotomy, to large revision mastoid cavity, to demonstrate cavity obliteration with bone pate, cartilage and in some cases muscle-periosteal flaps. In all cases the tympanic membrane and ossicular chain are also reconstructed. Ossiculoplasties include incus or malleus head interpositions and Titanium PORP or TORP. All edited to total run time of 18 minutes.
8 - Revision Tympanoplasty
8.1 - 'Butterfly' cartilage 5mm graft, revision myringoplasty
'Butterfly' cartilage Myringoplasty, using initially a 4mm, and then, due to inadequate size, a 5mm graft. Inlaid to a perforation of tympanic membrane. Revision case, for residual posterior perforation after previous underlay graft to a larger perforation. Left ear. Shows some of the issues that can arise with this technique in less than ideal situations. No audio, with subtitles.
9 - Revision Mastoidectomy
9.1 - Facial nerve graft and revision mastoidectomy
Revision mastoidectomy for residual cholesteatoma, traumatic disruption of facial nerve at posterior genu, and damage to inner ear causing profound hearing loss. Nerve graft with greater auricular nerve. Cavity revision and obliteration. Mike smith, with audio
9.2 - Mastoid cavity revision, and layered obliteration
Wet mastoid cavity but intact drum and good hearing. postaural approach, cavity revision to remove mucosa and keratin, then obliterate in layers with packed bone pate, conchal cartilage sheets, superior based musculo-periosteal flap, and temporalis fascia; without entering middle ear. Mike Smith, with audio
9.3 - Revision mastoidectomy, exposed VII and lat scc fistula, TORP with omega shoe, obliteration
Revision mastoidectomy, exposed facial nerve (VII) and lateral semi-circular canal fistula, TORP ossiculoplasty with titanium Kurz footplate omega shoe, mastoid cavity obliteration
9.4 - Revision Radical Mastoidectomy with TORP and cavity obliteration
Revision radical mastoidectomy, Right ear. Recurrent cholesteatoma, wet perforated atelectatic tympanic membrane, wet cavity, absent ossicles, conductive hearing loss. Cartilage tympanoplasty and cavity obliteration, with bone pate and cartilage. Ossiculoplasty using Kurz titanium Total Ossicular Replacement Prosthesis (TORP)
9.5 - Revision MRM, cavity obliteration, titanium PORP
Revision, left ear, canal wall down mastoidectomy, in fairly sclerotic mastoid bone, with tympanoplasty, harvest cortical bone graft from mastoid, Kurz titanium ‘bell’ partial ossicular replacement prosthesis (PORP) ossiculoplasty, cavity obliteration with bone pate and cartilage, wide meatoplasty. Mike Smith, with audio description.
10 - Stapes surgery
10.1 - Stapedotomy, KTP laser to crura
Stapedotomy by permeatal microscopic approach. Left ear. Bony canal narrow and obscuring some annulus. Indication: otosclerosis and conductive hearing loss. Procedure: Anterior focus of otosclerosis is seen. Stapes crura are divided using KTP laser. The stapedotomy in the stapes footplate made using diamond ‘Skeeter’ drill. Wire and Teflon stapes piston inserted and hook crimped. Fat grafts from ear lobe placed in oval window niche. Mike Smith, with audio description.
10.2 - Stapedotomy for otosclerosis, using ‘SMART’ Nitinol and Teflon piston and KTP laser
Stapedotomy for 67 year old male, right ear. Indications: otosclerosis causing conductive hearing loss. Procedure: stapes crura divded with KTP laser, stapedotomy with diamond ‘Skeeter’ drill. Nitinol and Teflon stapes piston trimmed to length. Crimped by laser. Fat graft seal from ear lobe placed around piston in oval window niche. Mike C F Smith, with audio
10.3 - Stapedotomy, KTP and Nitinol
Left ear, permeatal, microscopic approach. crura divided with KTP laser, stapedotomy with diamond Skeeter burr to footplate. Nitinol and Teflon, 'Smart' piston, hook closed using single shots of KTP laser. Fat from ear lobe placed in OW niche. No sound, with subtitles.
11 - Other
11.1 - Traumatic round window rupture with perilymph leak, dead ear. Tympanotomy and seal persistent perilymph leak
A young boy received a slap trauma to the ear. He developed a profound sensori-neural hearing loss in that ear, and some mild vertigo. He presented after several weeks. Indications: to explore ear and check for persistent perilymph leak due to possible stapes dislocation or window leak, because this would leave him at risk of meningitis with any URTI. Procedure: tympanotomy, identification of RW leak and place tissue seal
11.2 - Glomus Tympanicum removal, with KTP laser
Small Glomus Tympanicum tumour visible through tympanic membrane as a pulsatile red flush, removed by canal-pasty and tympano-meatal flap, with bipolar cautery plus KTP laser.
11.3 - Blind sac closure of ear canal
Chronically infected ear with poor response to medical and surgical care, no residual hearing. Mucosal disease cleared from middle ear, mastoid and ear canal. Eustachian tube, middle ear, mastoid cavity and ear canal obliterated and sealed in layers, and ear external meatus closed.
11.4 - Massive aural polyp excision, with canalplasty and tympanoplasty
On a rural ear camp in remote western Nepal, a patient has a very large chronic aural polyp coming out of ear meatus. This arises from a large perforation of the ear drum. The middle ear is full of bleeding granulation tissue, but the ossicular chain is intact. The polyp and inflamed tissues are cleared and the drum reconstruction.
11.5 Spontaneous CSF leak into middle ear, trans-mastoid repair of tegmen
Elderly man presented with CSF leak into the middle ear and mastoid, through a large tegmen tympani defect. His hearing was good for age. The leak was approached via an extended cortical mastoidectomy and repaired in layers with bone, cartilage, and soft tissue grafts. Hearing and ossicular function was maintained.
11.6 Endolymphatic Sac Drainage
Endolymphatic sac, or saccus surgery for Ménière's disease has been a controversial topic. However some patients do appear to get sustained symptom relief, though the mechanism and pathology behind this is much debated. Whether to merely decompress the bone overlying the sac, or incise and drain the sac is debatable, and some now advocate identifying the endolymphatic duct and clipping this. The approach varies with changing theories of the normal and the disordered function of the saccus. This video demonstrates an approach to the sac and its duct. This surgical option may be suitable when medical measures such as conservative management or intra-tympanic injections of steroid have failed to give adequate relief and when there is still useful residual hearing in that ear. Usually existing hearing is retained with this procedure.
