Defensive chronic ear surgery

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Abstract
The surgery for chronic ear disease has been modified in recent years because of the advances that have been made in neuro-otologic surgery including improvement in equipment and surgical techniques. There have been significant advances in the treatment of the acute phase of the inflammatory diseases of the middle ear and mastoid; however, there still remains a significant group of patients that require surgical correction of inflammatory disease of the middle ear and mastoid. A defensive approach to chronic ear surgery has been developed. This includes a proper preoperative evaluation of the patient's middle ear or mastoid problem with office microscopic examination of the ear and proper radiographic and audiologic studies. Surgical techniques include all the aspects of neuro-otologic surgery including an excellent otologic drill and suction irrigation. The point is made that careful defensive chronic ear surgery is best done with blunt instruments to avoid injury to soft tissue structures. A systematic approach to the removal of the disease from the ear is presented including the defensive approach of expecting complications and making preparations to avoid injuries as a result of these complications. This includes positive identification of the facial nerve, identification of labyrinthine fistulas, and cholesteatoma involvement of the posterior and middle fossa. Two cases are presented to illustrate how this defensive approach to chronic ear surgery may allow systemic resolution of very difficult chronic ear problems with preservation of neurologic and labyrinthine function.

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