Exploratory Tympanotomy Periprocedural Care

Patient instructions

Postoperative instructions are given to the patient prior to surgery. This often assists patients in their preparation for surgery. Patients are instructed to keep dry ear precautions until healing inside the ear canal is complete. They should avoid forceful nose blowing, closed-mouth sneezing, or autoinflation of the ears to prevent inadvertent mobilization and displacement of the tympanomeatal flap that has been stabilized with ear canal packing.

Elements of informed consent

When exploratory tympanotomy is indicated, the otosurgeon should explain, in the simplest of terms, to the patient that the surgery will be performed through the ear canal so that the eardrum can be raised and the middle ear can be entered. The goals of the surgery, whether to identify/correct a conductive hearing loss, to obtain direct visualization of the middle ear and it structures, or to retrieve tissue from the middle ear for diagnosis, must be clearly delineated.

Potential risks and complications include bleeding, infection, tympanic membrane perforation, altered taste or dysgeusia, dizziness, hearing loss, and facial paralysis.

Options and alternatives to the surgery should be discussed in the preoperative counseling. This is usually case specific and individualized. Hearing alternatives may include a conventional hearing aid or bone-anchored hearing apparatus.

Anesthesia

Exploratory tympanotomy may be performed under intravenous sedation/monitored anesthesia care (MAC) or under general endotracheal tube anesthesia. The choice of which anesthetic to be administered depends on surgeon and patient preference. If the patient’s hearing is to be tested intraoperatively, IV sedation/MAC is undertaken. This is particularly useful for the surgeon to not only receive immediate verbal feedback from the patient with regards to hearing changes, but also if any dizziness or facial contractions occur with surgical manipulation of the vestibule or tympanic facial nerve, respectively.

Positioning

Patient positioning during exploratory tympanotomy is the same as for other otologic surgeries. After induction of general anesthesia, the operating table is turned 180°. The anesthesiologist is now situated at the foot of the bed. The surgeon is at the head of the bed.

If the operation is carried out under IV sedation/MAC, provisions are made to suspend the drapes off the patient’s face. A pillow is placed under the knees to prevent strain on the patient’s lower back lying supine.

Necessary surgical equipment required past the exploratory phase of middle ear surgery should be available. These include the gamut of ossicular and stapes prostheses, high-power drills for mastoidectomy, and stapes microdrill.

Equipment

Equipment required for exploratory tympanotomy includes operating microscope and standard middle ear surgical tray.

Rigid oto-endoscopes may be incorporated into an exploratory tympanotomy. These are particularly useful to visualize areas that are difficult to see through the straight line of sight obtained from the operating microscope. Difficult to visualize areas include the protympanum, sinus tympani, and aditus ad antrum. Oto-endoscopes come in a variety of thickness (2.7 mm or 4 mm) and view angles (0°, 30°, 70°).

Intraoperative facial nerve monitoring may be used during exploratory tympanotomy if middle ear anatomy is distorted or surgical manipulation in the vicinity of the tympanic facial nerve is anticipated. The monitoring unit is also able to deliver electrical current to stimulate and verify the position of the facial nerve.

Exploratory tympanotomy is typically performed in the outpatient setting. The postoperative patient should return to the office in one week to check that the canal packing is secure and not infected. Topical drops are used to moisten the packing that will be removed in 2-3 weeks. Hemotympanum should resolve in several weeks. The tympanomeatal flap is checked to make sure that it has healed in place and that no perforation exists.