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Dr. Cassius Vinicious C. Reis: Principles of temporal bone surgical anatomy

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A Colour Atlas of Temporal Bone Surgical Anatomy

This typically requires a monitored bed in the hospital, however. Normal coronal view of the temporal bone. Proper postoperative appearance of a canal wall up mastoidectomy. Note that the tegmen black arrow and the posterior—superior ear canal are intact white arrow. Proper postoperative appearance of a canal wall down mastoidectomy. In this case, the tegmen is intact, but the tympanic membrane lies across the horizontal and vertical portions of the facial nerve because the ear canal has been removed.

There is also a large meatoplasty, and the ear canal slopes downward to promote healthy drainage. Inadvertent injury to the tegmen, and possibly also the dura, can lead to a temporal lobe encephalocele. This may not occur immediately after surgery but even years later. This image depicts an encephalocele into a canal wall up mastoidectomy. This reflects transmitted brain pulsations to the middle ear and mastoid air space.

It can be noted both with binocular microscopy and on tympanometry when the patient is sitting upright. This sign usually resolves when the patient is laid flat so that the brain does not exert as much downward pressure. Treatment for an encephalocele is surgical. The incision is a standard postauricular incision that extends superiorly.

The temporalis is exposed superiorly and the sternocleidomastoid muscle attachment to the mastoid process exposed inferiorly. The periosteum over the mastoid process is elevated to the ear canal. The temporalis muscle is then retracted off the skull anteriorly. A standard cortical mastoidectomy performed to expose the encephalocele asterisk.

For a small encephalocele, particularly those in patients that have never had mastoid surgery before, a mastoidectomy does not need to be performed as the encephalocele can be treated through a middle fossa craniotomy alone. A middle fossa craniotomy is performed. This can be centered over the area of the encephalocele identified by preoperative imaging to allow it to be quite small. Details of this opening are given in Chap. Extradural dissection with a periosteal elevator is performed to trace around the circumference of the dural defect. Large, plunging encephaloceles do not contain viable brain.

A bipolar cautery is used to carefully divide the devitalized brain below from the healthy brain above. After this process, the healthy brain typically retracts up, and it is important not to lose track of any bleeding vessels when this happens.

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Meticulous hemostasis inside the dura is necessary. A three-layer closure is performed. The superior layer is a dural patch consisting of fascia, cadaveric dura, or artificial dura i. A larger piece than one expects to use is carefully inserted through the dural defect and the edges tucked up between the brain and the dura.

Surgery of the Ear and Temporal Bone

Thus, the downward pressure of the brain when the patient is upright will help seal the defect. We usually cover this with a dural sealant as well i. The inferior layer is the bone graft. The bone flap removed during the craniectomy is cut and a portion of it used to bridge the bony defect in the tegmen. Usually, we cut the anterior half off and use it to reconstruct the tegmen.

It is important to make sure it is laid on top of the medial edge of the defect for support.

Sometimes, it is hard for the bone graft to stay in the appropriate location. In this case, it can be plated to the skull to prevent lateral migration. Finally, the posterior half of the temporalis muscle is separated from the anterior half vertically and then rotated between the dural patch and the bone graft to form the middle layer.

This should be sutured to a hole drilled in the skull or to the soft tissue around the ear canal to prevent the muscle from retracting out when the patient wakes up and begins to chew.