Dedication

This manuscript is dedicated to:

My late father, Mohammad Nasib, who wrote many books in his

lifetime and promoted education in all spheres of life.
My loving mother, Ashraf Sultana who has been the spirit behind
my career.
My caring wife Qudsia and loving children Zaayer & Saad, who
always gave me ample space and time for my educational activities.
My mentor Mrs. Bakhtiar Jafari, FRCS, who spent all her efforts on
my basic training and continues to support me even today.
My colleagues at Services Institute of Medical Sciences/Services
Hospital, Lahore, in particular Dr. Khalid Cheema and Dr. Mazhar ul
Islam who have always been very supportive without which this
workshop would not be possible.

Mohmammad
Mujeeb

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Contents:
Page

Dissection lab 3
Work station 3
Instructions to use Microscope 4
Instruments 5
Drill machine 5
Temporal bone holder 5
Preparation of temporal bone 6
Surface anatomy of temporal bone 7
Tips for temporal bone dissection 8
Cortical Mastoidectomy 9
Transmastoid Epitympanotomy / Atticotomy 13
Posterior Tympanotomy 14
Permeatal Tympanotomy 17
Atticotomy 19
Facial nerve decompression 20
Canal wall down Mastoidectomy 22

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Dissection Laboratory

Workstation

3
Instructions to Use Microscope

Ensure that eyepieces are fully inserted and set at zero.

Change the magnification to higher level.
Focus the microscope on a superficial bony landmark of the
temporal bone using one eyepiece at a time.
Now change the magnification to the lowest level and adjust
your focus.
Finally the inter-pupillary distance is adjusted keeping both eyes
open.
Clean the microscope after you have finished the dissection.

Correct setting of the eyepiece.

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Instruments

Following instruments are provided for the dissection

Knife
Scissors
Tooth forceps
Cutting and Diamond burrs
Crocodile forceps
Micro-scissor
Plester’s knife
Rosen’s knife
Drum elevator
Straight pick
Curved pick
Middle ear curette
Suction cannulas
Suction machine
Warning: Please ensure that the water level in the
suction bottle is kept below the upper level in order to
avoid damage to the suction machine.

Drill Machine

The micromotor Drill machine provided for dissection has a control

panel with a knob for maximum speed adjustment. It has a foot pedal
for controlling the speed. The motor is sensitive so that it may get
damaged by the entry of water or by over heating if it is run covered
in the polythene cover.

Temporal Bone Holder

The Temporal bone holder can be moved around its pivot joint
for the ease of dissection.
Place the temporal bone holder in such a way that the drain
outlet is in a dependant position and is connected to a drain
tube.

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 Completely unscrew the knobs of the holder and place the
temporal bone in such a manner that Zygomatic arch and
Glenoid fossa are away from you i.e. surgical position.
After ensuring the desired position of the bone, the knobs are
tightened to fix the bone in the holder.
Keep the temporal bone holder clean of bone dust, soft tissue
and accumulated water at regular intervals.

Preparation of temporal bone

Soft tissue over the bone is removed by two incisions down to

the periosteum with a heavy knife.
The first incision is along supramastoid crest and second incision
is along the posterior canal wall, perpendicular to first incision;
soft tissue above and behind these incisions are removed.
Expose the tip of mastoid with a sharp knife.

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Surface Anatomy of Temporal Bone

Identify the following landmarks on the temporal bone provided.

Zygomatic arch
Glenoid fossa
Supramastoid crest ( Linea temporalis )
External auditory canal
Tip of mastoid
Spine of Henley
Middle cranial fossa
Posterior cranial fossa
Petrous temporal bone
Internal auditry canal
Arcuate eminence
Sigmoid sinus
Jugular fossa

Fig 1. Lateral surface of a left temporal bone. AT Anterior zygomatic tubercle, F Glenoid fossa, H Spine of
Henle, MP Mastoid process, PT Posterior zygomatic tubercle, S Vertical portion of the squamous bone, SP
Styloid process, T Tympanic bone, V Vaginal process, ZP zygomatic process, Roof of the external auditory
canal (squamous bone), < Tympanosquamous suture line, > Tympanomastoid suture line.

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 Fig. 2 A closer view of the external auditory canal and tympanic ring area. FN Facial nerve, MT mastoid tip,
SB Squamous bone, TB

Tips for Temporal Bone Dissection

Hold the drill hand piece in your right hand like a pen.
Use your left hand for holding suction/irrigation cannula.
Stabilize your right hand with your little & middle fingers resting
on the temporal bone/holder.
Use the largest possible burr for a given area of dissection.
Do not keep the running burr at one point i.e. keep moving it
from the area of dissection.
Always keep your eyes beneath the burr.
Always keep suction/irrigation cannula along with the burr during
dissection.
Continuous suction/irrigation is mandatory to remove the bone
dust and to prevent thermal trauma to underlying structures for
example facial nerve. This is particularly important when
diamond burr is being used for dissection.
Copious irrigation will also keep the burrs and suction tips from
clogging.
Stop rotating burr before introducing or removing it from the
operative area.
Do not apply pressure to cut faster.
Use side of the burr rather than its tip.

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 Always move the burr parallel to an important structure for
example facial nerve, sigmoid sinus.
Damage to an exposed important structure can be prevented by
placing a piece of suture foil over it.

Cortical Mastoidectomy

Cortical mastoidectomy is started in the area called Triangle of

Attack, the boundaries of which are:
1. Linea temporalis (Supramastoid crest)
2. A line behind the posterior canal wall vertically down
from the linea temporalis to mastoid tip
3. Third line joins the posterior part of linea temporalis to
mastoid tip

This triangle of attack is marked with the largest cutting burr.

Fig.3 The triangle of attack has been created in a left temporal bone. MCF
Level of the middle cranial fossa, SS Expected level of the sigmoid sinus, T
Posterior tangent to the external auditory canal.

Using large burr drilling is started within this triangle.

It is of utmost importance to keep the boundaries of the triangle
saucerized.
The cortical cells are dissected away while carefully preserving
the following structures:
Middle fossa plate superiorly
Sigmoid sinus posteriorly
Posterior canal wall anteriorly
Mastoid tip inferiorly

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Korner’s Septum, if found, should be removed.

Fig.4 Mastoidectomy has been started. MFP Middle fossa plate, MT Mastoid
tip

Identify the mastoid antrum and widen it all around by removing

the peri-antral cells avoiding contact of the drill with the
structures in the depth.
The first important structure to be identified in the depth of
mastoid antrum is the lateral semicircular canal.

Fig.5 The antrum (A) has been opened, and the lateral semicircular canal
(LSC) has been identified.

Carry your dissection forward from the mastoid antrum to

identify the aditus ad antrum which is widened all around.
Copious irrigation of the area helps to identify the shadow of
short process of incus much earlier. This maneuver averts

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unintentional dislocation of the incus with the rotating burr or
with the Aditus Seeker, which must be avoided at all costs.

Fig.6 The short process of the incus (I) has been identified. LSC Lateral
semicircular canal, MFD Middle fossa dura, SS Sigmoid sinus

Tip of the short process of incus is the superior landmark for the
mastoid segment of facial nerve.
The posterior canal wall is thinned down to paper thickness.
The Sinus plate & Dural plate are identified and preserved.
The Sinodural angle is opened up by clearing the cells.
The dissection is then carried towards the tip of the mastoid
clearing the cells systematically i.e. peri-labrynthine cells, peri-
sinus cells, tip cells and retro facial cells.
Digastric ridge is then identified running anteroposteriorly from
the lower end of sigmoid sinus.
Anterior end of digastric ridge points towards the stylomastoid
foramen.
A line joining the tip of short process of incus with the anterior
end of digastric ridge marks the course of mastoid segment of
facial nerve.

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 Fig.7 The digastric ridge (DR), the short process of the incus (I), and the lateral
semicircular canal (LSC) are the landmarks for the mastoid segment of the facial
nerve. SS Sigmoid sinus

Landmarks of completed Cortical

Mastoidectomy

Cortical masoidectomy is completed when following landmarks

are visible:

Thin dural plate.

Thin sinus plate.
Thin posterior canal wall.
Widely open mastoid antrum showing the dome of laeral
semicircular canal.
Adiuts ad antrum showing the short process of incus in its floor.
Well dissected tip cells delineating the digastric ridge.

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Transmastoid Epitympanotomy /
Atticotomy

After completion of cortical mastoidectomy dissection is carried

forward through the aditus towards the attic by removal of
posterior attic cells. Keep in mind the following pre-cautions
while working in this area:

A cutting burr suitable for the space between superior canal wall
and tegmen tympani is selected. A larger burr will damage the
superior canal wall or the tegmen and may cause damage to
dura. A small burr on the other hand will take much longer to
dissect and may also penetrate unwanted structures.
The drill should move from inside to outside i.e. medial to
lateral, and forwards.
Extreme caution should be taken to not touch the incus &
malleus with running drill.

Fig.8 Transmastoid atticotomy is being carried out. Note the size of the diamond burr used for
this step. The direction of movement should be from medial to lateral.
FN Facial nerve, I Incus, LSC Lateral semicircular canal, MFP Middle fossa plate

As the dissection moves forward the body of incus and the head
of malleus are identified with their attached ligaments. Anterior
to the head of malleus a vertical ridge of bone running down
from the tegmen will be identified. This is the COG, which is a

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 friendly landmark for the geniculate ganglion of facial nerve.
Removal of cog exposes the anterior epitympanum which may
have few cells to be cleared. There will be some cells in the
medial attic wall, careful clearance of which exposes the junction
of the lateral and superior semicircular canal ampullae. By
changing the angle of view one may appreciate the tendon of
tenser tympani with processus cochleariformis and attaching to
the neck of malleus.

Fig.9 Atticotomy has been completed. ^ Superior suspensor ligament, AAR Anterior attic recess,
DR Digastric ridge, FN(m) Mastoid segment of the facial nerve, I Incus, LSC Lateral
semicircular canal, M Malleus, MFP Middle fossa plate, PSC Posterior semicircular canal, SS
Sigmoid
sinus

Posterior Tympanotomy

Working under higher magnification, posterior tympanotomy is

performed through the facial recess to gain access to posterior part of
mesotympanum and sinus tympani.

Ensure that:

Posterior canal wall is paper thin with no air cells in it.

The incus and dome of lateral semicircular canal are visible.
Digastric ridge is well defined.
Copious suction/irrigation is used to prevent thermal trauma to
facial nerve.

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Opening the Facial Recess

Skeletonize the mastoid segment of facial nerve between long

process of incus and anterior end of digastric ridge with a large
diamond burr working parallel to the course of the nerve.

Do not run the drill across the direction of facial nerve.

Fig.10 The mastoid segment of the facial nerve (FNm) has been skeletonized
DR Digastric ridge, I Incus, LSC Lateral semicircular canal,
SS Sigmoid sinus

Perifacial cells will be encountered during this part of dissection. The

pinkish white colour of facial nerve will be seen through the thinned
out bone.
Identify the origin of the chorda tympani nerve and follow it running
anterosuperiorly on the posterior wall of EAC.
Follow the cells between the facial nerve and the chorda tympani
nerve, working anteromedially and parallel to the posterior canal
wall with 2 mm or smaller diamond burr.
Keeping a strut of bone under the short process of incus will
define a triangular area, the boundaries of which are the facial
nerve medially, chorda tympani laterally and the bridge of bone
superiorly.
Care is taken to avoid damage to the chorda tympani, facial nerve
and annulus tymapnicus.
Once the middle ear is entered, the opening is enlarged in all
directions except inferiorly where the angle between the facial
nerve and chorda tympani nerve will not allow doing so.

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 Fig.11 Posterior tympanotomy has been performed, conserving the chorda tympani (CT). A
strut of bone (S) has been left behind to protect the incus (I) from the rotating burr. Note that in
this case, the round window exposure is complete, making this amount of posterior
tympanotomy sufficient for a cochlear implant procedure. FN(m) Mastoid segment of the
facial nerve, LSC Lateral semicircular canal, P Pyramidal process, RW Round window, ST
Stapes

Through the tympanotomy following structures should be

visible:
Promontory, round window, stapes and the incudostapedial joint,
stapedius tendon, pyramid and the tympanic part of facial nerve.
By tilting the microscope the medial surface of tympanic membrane
and handle of malleus will also be visible.

Cautions:

Use higher magnifications.

Large diamond burr for the initial part of dissection and the
smaller one for the latter part.
Copious suction/irrigation.
Always work parallel to the direction of facial and chorda tympani
nerves and do not run the drill across them.
Shaft of the running drill may damage the facial nerve, so
take utmost care to avoid such mishap.
Avoid damage to the annulus tympanicus by keeping the deep
posterior canal wall intact

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Permeatal Tympanotomy

Permeatal tympanotomy is performed to evaluate the status of the

ossicles and to clear diseases from posterior part of mesotympanum
and sinus tympani. This is the approach used for stapedotomy and
ossicular reconstruction.

An incision is made from 6’O clock to 12’O clock position on the

posterior wall of EAC. The central part of incision is about 6 mm
away from the annulus. The extremities of incisions are close to
the tympanic membrane.

Fig.12 6’ O clock to 12’O clock incision in the posterior meatal wall for tympanomeatal flap.

Meatal flap is now elevated towards annulus with the help of

drum elevator.
Middle ear is entered by elevating the annulus in the
posteroinferior part with annulus dislocator and then gradually
the superior and inferior part of the annulus is freed taking care
not to injure the chorda tympani nerve.
Do not start dislocating the annulus in the postero-superior part
to avoid injury to the chorda tympani nerve.

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 Fig.13 Tympanomeatal flap being elevated.

The tympanomeatal flap is then folded anteriorly exposing the

incudostapedial joint. Further exposure of this area is gained by
removing the posterosuperior bony overhang with curette or
diamond drill.

Fig.14 Tympanomeatal flap folded anteriorly. Posterior superior bony overhang being removed to expose the
incudostapedial joint and pyramid.

This exposure should be sufficient to reveal the long process of

incus, round window, the whole extent of stapes, the horizontal
segment of facial nerve, the stapedius tendon and the pyramid.

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To perform stapedotomy the incudostapedial joint is disloacated
followed by division of stapedial tendon, removal of stapes
suprastructure and then making a whole in the foot plate of stapes.
Finally stapes prosthesis is inserted.

Fig. 15 Tympanomeatal flap has been elevated and folded forwards. Note that the TM has also
been freed from the handle of handle of malleus is sometimes required to gain access to the
anterior mesotympanum. Also the incudostpedial joint has been disarticulated.

Atticotomy

Atticotomy is performed to deal with limited attic disease or as

part of inside out technique of attico-antrostomy.

Upper part of the incision for permeatal tympanotomy is

extended forward and pars flaccida is elevated to expose the
scutum.

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 Using a suitable sized cutting burr the scutum (outer attic wall)
is removed up to the tegmen tympani. This dissection will
expose the head of malleus and body of incus in the attic area.

Anterior extent of the dissection should be up to the anterior

buttress to expose the anterior epitympanum completely.

Extension of dissection through the posterior epitympanum will

reveal the aditus in the floor of which lies the short process of
incus.

Horizontal segment of the facial nerve lies deep to the ossicles

and just above the stapes.

The disease may be followed towards the antrum if required.

Fig. 15 Atticotomy has been completed. Observe the exposed head of

malleus and body of incus in the attic.

Facial Nerve Decompression

Use higher magnification.

Localize the facial nerve in the horizontal segment through the

posterior tympanotomy and the vertical segment in the mastoid.

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 Do not touch the ossicles with a running drill.

Using a large diamond burr, with parallel strokes and profuse

suction/irrigation, the bone covering the posterolateral aspect of
the mastoid segment of facial nerve is gradually taken down till
the thin blood vessels of the nerve can be seen through it.

To prevent damage to the lateral semicircular canal, the bone

covering the anterior aspect of the second genu is similarly
thinned down i.e. do not remove the bone covering the
posterolateral aspect of the facial nerve in this area.

Fig. 16 Facaial nerve fully exposed in it’s mastoid and tympanic segment. This part of the
dissection also demonstrates the opened superiror and lateral semicircular canals which of
course is not the part of facial erve decompression.

Using a small diamond burr, the lateral aspect of the horizontal

aspect of facial nerve is also similarly treated.

Keep in mind that the horizontal segment and the second genu
may already have a bony dehiscence of facial canal.

Anterior part of dissection is carried towards the geniculate

ganglion, which is just anterosuperior to processus
cochleariformis.

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 To effectively complete this procedure you may have to
disarticulate and remove the incus.

The thin bone remaining over the facial nerve is then removed
with a blunt elevator.

After complete exposure of the nerve the sheath is then opened

with sharp needle.

At the stylomastoid foramen the periosteum of the digastric

ridge blends with the sheath of the facial nerve so that it is
difficult to isolate the two.

Canal wall down Mastoidectomy

At this stage you’ve completed cortical mastoidectomy,

transmastoid epitympanotomy, posterior tympanotomy and
exposure of the facial nerve. So far the procedure is canal wall
intact mastoidectomy.

Removing the posterosuperior canal wall along with some

additional maneuvers will convert it into canal wall down
procedure i.e. modified radical or radical mastoidectomy.

Using a large cutting burr the posterosuperior canal wall is

removed until a small bridge of bone is left between
epitympanum in front and the aditus / mastoid antrum behind.
This bridge of bone is conventionally called The Facial Bridge.

Remove the bridge with a curette or with a smaller cutting burr.

The anterior buttress is flattened down to the anterior canal wall

while the posterior buttress is similarly lowered down to the
posterior canal wall.

Normally a “ridge” of bone is left over the vertical segment of

facial nerve and this is conventionally called The Facial Ridge.

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Fig. 17 Modified Radical Mastoidectomy. Ossicles and TM remnant are
retained.

Do not miss the following steps:

Leveling down the floor of EAC with that of the middle ear which
may also have to be drilled down with a diamond burr in case
there is disease in the hypotympanum.

Exposure of the sinus tympani for the purpose of disease

clearance requires careful opening of the facial recess from the
meatal side.

The floor of EAC should also be leveled with that of mastoid

cavity.

If there is a deep cavity at the tip of mastoid the later may be

drilled out.

***************

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