I want to talk to you about two surgical problems 

of the external auditory canal.

Now,

one of these is very common but usually 

doesn't require surgery.

That's the diffuse exhaust Asus scene.

So commonly in swimmers,

it's bilateral symmetrical.

The surgery when it's necessary can be rather 

difficult.

And the other problem is the is the one of the 

exhaust Asus 

that's isolated.

Now,

we usually call these an osteo MMA,

it's a unilateral lesion and 

it invariably is surgical.

It's not common,

but it is a surgical problem.

In most cases,

it is unilateral and the surgery here can 

be quite simple,

particularly simple compared to the management of diffuse 

exhaust.

Oh sis,

I'm going to demonstrate these to you on slides 

but also on some 

videotapes from our temporal bone 

surgical dissection courses.

I think you'll find it quite interesting.

Now,

this is the relatively 

typical picture of diffuse exhaust doses of the 

external auditory canal.

Here's the short process of the malice.

You can see a fair amount of the drum.

You have these huge cecil 

exhaust osi's with some that are not 

quite a cecil.

Actually,

this patient has not got enough closure of the 

air canal probably to warrant surgery.

And let me talk to you just a little bit about what the 

indications are for surgery.

I think it's important to stress the fact that 

regardless of how these diffuse exhaust 

osi's look and certainly the one I just 

showed you on the slide,

uh,

probably doesn't need to have surgery.

It isn't certainly closing the ear that much.

We operate.

Not on a basis really of the way it looks,

but on the basis of the symptoms that's giving the individual.

Now,

the major symptoms are those involved 

with getting water trapped deep to 

the exhaust gasses or the recurrent 

problem of,

of otitis external.

Uh,

the easiest way to handle these medically is to 

just have the patient douche the air with 

ordinary rubbing alcohol after swimming and they can 

usually control the situation.

However,

if it's not controlled,

if they persist in having symptoms 

intermittently,

or if your observation has led you to 

believe that continual 

progress of the problem you've been watching is going to in 

fact,

result on closure of the ear canal,

then obviously surgery should be done.

Now,

the surgery here can be rather tricky 

because the ear canal,

in fact is almost closed by the 

lesion.

The major risks of complications 

are to number one,

Tearing the Eardrum,

well,

that can be fixed at the time of surgery.

And I forewarn all these patients that there's at least 

a 10% chance that I may have to repair the eardrum 

in connection with the surgery.

The other risk and knock on wood.

I haven't had this happen to me.

I sure have had perforations from some of these.

But the other complication is the matter of sensory neural 

hearing impairment.

And if you air and let the 

bird touch the Malley's because these people 

have intact ear drums intact are 

secular chains and normal hearing.

Let me show you a little bit about the surgical 

approach.

Now,

I think the biggest mistake that people make when they 

encounter something like this is to treat it as a simple 

problem.

Simple problem,

meaning approach it through the external auditory.

Me.

A dis that's a mistake.

That's a mistake that can lead to 

perforation of the eardrum,

incomplete surgery and very 

difficult exposure.

What you want to do and what I do in all 

these cases is to go behind the ear.

But this will help show you what,

what the real problem is.

Let me point out here.

This is the,

here's your promontory,

here's your facial nerve,

here's the Mallia.

So this is the ear drum.

Here is the 

cecil eggs,

osteoporosis on the 

anterior inferior wall.

And here you have it on the posterior 

superior,

you see what you've got and you've got to get down here and get 

this off and you've got very little space as you'll 

see from the surgical sequence.

So I like to approach them post auricular lee turn the 

air forward,

make sure that your incisions come far enough forward,

both inferior and superior early 

to get an adequate view of the ear canal.

Now,

what you're looking into then are these 

few sex osteoporosis?

And what I do,

I take the skin,

I take the skin from the this 

point all the way out,

totally out of the ear,

take a large drill and just start drilling on 

this and keep drilling on it,

taking off the exhaust until you get 

to the point where this starts to open up.

In other words,

once you get to about this point here,

then you switch and you start going to smaller 

birds and working on the individual areas 

and you actually sort of eggshell it,

you end up by having this all very s 

excavated.

And once you've got it very excavated,

then you can take a cure or a diamond 

stone and get off the remnant.

Now,

essentially what we've done we did was to take the 

skin out of the outer half of the ear canal,

we pushed the skin of the inner half 

forward of us as we worked with the 

drill and in the final steps and once you get 

this off,

you just lay the skin back in place.

Now,

I'm gonna show you now the first 

surgical sequence.

Uh and we'll make a few comments as we 

go along in the area where you can 

see the eardrum is right at this area here.

Now,

the problem is how do you go about approaching this sort of case?

Well,

I'll tell you the one thing you shouldn't do in my experience 

don't do them through the ear canal.

It would seem logical but it's much better to come 

in from behind.

First thing I'm gonna do is to develop a 

this area here that between the tempo gnome 

asteroids future at this point 

and the temple suture,

what it is here so that I have a little,

this little flap of skin that's normally attached to the 

oracle.

Now let me have a number two knife,

I will try to cut across the base of that at 

this point here,

cut across the base of it and free that up.

Okay.

Now,

that will serve as a little skin flap to 

cover this area here.

Alright.

Now let me have,

let me have a beaver knife.

What I'm gonna do now is to make a circumferential 

incision because I'm gonna be taken 

off all of this skin and we'll make a 

circumferential incision coming around 

and joining up with this one right here.

Superior li then we 

will complete that around.

Now,

what I'm going to do,

let me tell you as I make this incision,

what I'm going to do is to take all the skin out of the 

ear until I get to 

the what amounts to the area where the exhaust 

doses are the most most 

prominent.

And then at that point,

I will dissect the skin off of them and 

elevate it towards the ear drama.

So I came in behind the ear,

made a post curricular incision.

And what I'm gonna send,

what I'm gonna do is just like I would on a chronic ear,

so to speak.

I'm gonna go ahead out of Muhlenberg one turn.

That's it.

Okay.

Now that you've seen that,

let me put in the retractor and then we'll go back to the 

microscope.

Well,

I guess I'll go back to looking through it myself.

Okay.

Now,

let me have a suction for here.

Let me have the frayer.

Now,

what we're gonna do here is to elevate this into their,

here's the area of the spine of Henley,

right?

There's millennia,

temporal,

here's the spine of Henley right there,

huh?

What we want to do now,

there's the strip that we created.

Let's have a weapon.

And what I'm going to do is to roll that out 

and I'll take my weapon and slip it in here 

like this and sort of lift up 

and lift up this way you see.

Okay,

fine.

We'll reset the retractors again and get 

it under the vascular strip like this.

All right.

Now,

out of trend Ellenberger turn,

if you would,

okay.

At this point,

I'm just going to start off just like I would in a 

chronic ear.

I'm gonna start taking off the canal skin.

Now,

one other,

one principle in this surgery that I think is 

important is,

is get,

get adequate exposure and then don't be too 

conservative with the skin.

Don't,

don't try to,

don't fiddle around and try to,

you know,

pussyfoot along because of the fact that you won't 

want to take damage any of the skin.

You've got to get the exposure.

You've got to get the show on the road,

so to speak.

And at times that means sacrificing skin.

Now,

when you get down near the 

eardrum,

you start going very,

very slow.

Of course,

because you don't want these people to span has normal 

hearing and they invariably do.

And the a common minor 

complication is tearing the 

eardrum.

And I would suspect in one out of every 10 of 

these,

I do,

I have to do a minor little repair of the eardrum and that doesn't 

concern me,

but you don't want to touch our secular chain,

that's for sure.

Right now,

at this point,

we have started to take this off the exhaust 

osi's.

You see now,

what I do at this point is to get the skin,

try to get the skin out as quickly as 

possible.

I will dissect this down and roll the table towards me 

a little more as far as I can conveniently do so 

and then take out the outer half of the skin,

hold it,

get it down as far as I can get it this way and then 

get it out of the ear.

Alright.

And getting it out of the ear means putting an instrument.

Why am I doing,

putting an instrument here and sort of a vaulting 

it like this.

I don't,

I don't try to cut it gently and so forth 

because I found that when I do that 

too is,

is frustrate myself.

I just sort of put it down like that and pull out.

You see,

I've dissected the skin down to that point and I just put it 

down and sort of 

elevated,

so to speak.

Huh?

Put it down here like this in our 

instrument in and then just sort of,

if we can want to get as much as we can 

without spinning our wheels,

so to speak.

Now,

this is not the way I used to do when I first started 

doing,

these the first one I ever did,

I'll never forget it back in about 

1959 

and I did it through the ear canal and I learned my lesson 

there.

I had an ear drum to repair and all 

sorts of problems.

It's just not adequate exposure,

just not adequate exposure 

if I can get this out here.

See,

here again,

I'm,

I'm fiddling around right now.

I'm wasting time.

There's no point in trying to 

two.

You can't get all the skin out the way you'd like 

to in these cases.

So you just go ahead and sort of reach 

in and pull it,

which is what I'm doing now.

And should have done a minute ago.

All right.

Now,

at this point,

we ought to be able to take this out.

Yeah,

let me have a couple more steps.

This is our canal skin.

Now,

we immediately go to the drill,

rolling 

the water down a bit,

a little bit more.

Okay off a bit 

good.

So,

we just put this in and start drilling 

like this now as you drill in.

Oh,

let me have a rose and needle.

Let me show you the pattern that you watch as you drill in.

Well,

here's where one of the big exhaust osi's was.

Here's another one and here's another one.

And if you look at this pattern,

you see this is skin here,

there's a pattern and it follows a typical pattern of A 

Y,

one arm of the Y is here,

one arm of the Y is there and the other one is 

there and it follows that pattern.

And what you do is you keep drilling down with the center 

of your drilling right at this point here,

always staying on the lower side 

because you don't want to remember.

Don't forget your drum is nearer to you post eerily and 

superior early than it is anterior and inferior early.

So you sort of center,

you're drilling right at this point here.

Now,

as that area of soft tissue gets 

bigger opens up,

that means you're getting past your exhaust Asus.

And at that point when it starts to open up and there's 

more soft tissue,

then you start working on individual 

exhaust and elevating the skin in 

front of you.

Alright,

let's have a drill.

Now,

I am not concerned the two areas,

the areas that concern me in terms of my drilling,

I don't want to get into the annoyed fossa 

and cherry really if I can help 

it and I don't want to get onto the drum or into 

the,

onto the article.

So I tend to stay,

I keep my,

I tend to stay directed a little bit inferior and 

interior,

but keep watching to make sure that I'm not getting 

into soft tissue,

I probably will get into soft tissue.

But uh I don't want to get into it much.

Let's put it this way.

You want to recognize it when you do,

let's put it that way.

So at this point,

we're working,

you might extend some,

some extent without being able to see past where we're 

working.

But we're following down that soft tissue 

and knowing that and doing so that's where we're centering 

things that that's the way to go.

I tell all these patients when I do these,

that first place,

I don't do them on the way they look,

do them with rare exceptions,

you do them because of symptoms.

And I tell all of them that the,

the major risk and complications 

involved is tearing the drum,

which usually doesn't present much of a problem because you were 

repaired immediately and the other one is getting 

into our secular chain and getting into hearing loss 

as a result of a sensory.

No,

that's not happened to me yet,

but I'm sure if I do enough of them,

it will someday.

This is a relatively typical one 

in that the exhaust go are 

continuing to go down.

We're getting nearer and nearer to the drop.

One of the things that make one of the many things that makes 

these tricky operations if you haven't done them 

before,

is that constant question of how near to how 

did the drum am I?

You know,

you don't want to get into trouble.

Well,

there's a rule here.

Your question about it.

Always stay low and anterior.

That's the secret low and anterior.

That's where you have the most room.

Now,

let me show you something else you can do.

Let me have a number one knife.

Now,

at this point,

we're opening up a little bit and now we 

can try to open up this wire area 

and take a look to see how far,

let me have a number.

Let me have a number one knife.

Here's our skin.

We can start,

we can take a peek and find out how near the drum we are at 

this point and then we'll push that skin back 

in.

Now,

there's your drum right there.

Do you see that?

There's the drum?

Let's take a closer look at that and I want you to 

look not only where the drum is but the general 

angle of the drum.

If you look in here,

now we open that up and there's 

your drum.

Okay.

Now,

notice that the drum goes,

if you can see the orientation,

let me get you back.

Notice that the drum in that area is in this 

plane and that's the plane in which I've been 

drilling,

constantly keeping the deepest area of 

penetration and clearly inferior early.

So that as you go in,

you go in parallel to the drum surface 

on.

Alright,

again,

I'm gonna stay anterior and inferior.

The reason being you don't want to expose 

yourself up there until you've got a 

better view of things because that's where you're gonna get into 

obstacles and gonna get near the drum much quicker.

At this point.

I'm beginning to 

let's have the next smaller size drill.

Now,

at this point,

I'm beginning to scoop out the exhaust 

and leave an eggshell type of thing.

I'm not drilling on the area where their 

skin is.

I'm drilling back from that so that I'm trying to egg 

shell and then I can go in with a cure it and knock it off.

You see,

I realized that this is not a slide of this 

patient's ear,

but I wanted to point out something when I,

we go back into this sequence,

you watch right down in this area here and I 

expose the facial nerve in the ear canal 

and I'll comment on it later on,

but you'll notice that because I've done this and I 

realized that I started to change my 

procedure bit,

working more anterior and inferior early and 

being a bit more cautious than I might.

And I thought it might be a interest to you in connection with 

exposing the facial,

in the ear canal to take a look at some of the drawings by Ward 

Litten.

I apologize.

All the lettering is backwards,

but that's so that I can set this up as a right ear 

hears the tim panic membrane and 

this is the tim panic course of the facial 

and the mastoi portion.

And this drawing is out of an article by Ward Litton 

that appeared in the September 69 

Laryngoscope as I was working down the ear 

canal,

I actually got enough posterior to expose the 

facial nerve at about this point here.

Now,

if we look at this in another orientation 

here,

we're looking from behind forward.

Here's the tim panic membrane Angeles,

here's the facial nerve,

I exposed the facial nerve right at this point.

Here just goes to show that you can 

encounter the facial anywhere in the air.

The important thing is to realize that you're there.

Here's a case where the word visualize is 

quite properly used.

You've got to visualize the air drum 

because you can't really see it.

Well,

you've got to visualize where it is in terms of your 

working.

I'll get a little bit more vision and so forth.

No,

if it doesn't want to,

there we go.

Okay.

And we'll switch to a diamond bar.

One thing I could have done here,

but I elected not to.

I was a little,

I was a little bit surprised to find out I was this low down 

here.

Therefore,

I want to explore this more.

I could have left these edges of bone 

as a protection of my skin flat,

but I'm going to switch to a diamond.

So I don't really have to do that.

All right.

Take this.

Let me have the weapon again,

please.

Now we can open this up a bit more 

and take a little bit more.

Look at it again.

The secret of success in these is do it 

gently.

Now this these,

these really come right down on the drum.

This bone really comes down on the drum.

Now that I can see how deep I am 

and where I am now,

I will go ahead push this skin back 

in and we'll go ahead 

with a diamond drill.

I'm gonna work with a cutting board a little bit here 

superior because I've got quite a bulk of bone.

Alright.

Roll them.

All right.

Now,

let's go ahead and take a look here and see if we can at this 

point.

See AMBO is what I'd like to be able to 

identify.

Alright,

Dumbo is gonna be in here.

We're posterior to it.

Okay.

We're right now.

We are right at the annular ligament here after we 

get this bone off and I'm gonna leave that bone now as 

a protection and we'll go ahead and work up here.

We're still way posterior 

apparently.

All right 

off.

Let's have the next smaller sized bird 

at this point.

As you see,

I've identified the drum and I know my direction 

at this point.

I'm sort of keeping an eye on how thin the bone is 

getting.

Plus seeing if I get to 

the bone,

it looks like the annular,

bony annular,

but I'm drilling inside this shelf,

keeping it thinning it down as I go 

and it is protecting me from the eardrum 

question that's often asked in these,

well,

with all this and taking all the skin out,

how often do you get a stenosis,

do you know,

knock on wood?

I've not had one with this.

I think that that's unusual in my experience 

here is the way I've done them for years 

and I'm not aware of having one.

I suspect somebody else has seen one or two of mine,

maybe if I had any,

but I haven't seen him.

They just seem to do beautifully.

They end up by being covered with skin 

for the most far.

All right.

Now,

let me have the stay peas,

cure it and we'll take off some more of the bone here 

and flip it off.

It looks relatively thin 

like this.

Huh.

Put it in trying to get it off.

Leaving the skin behind 

like this.

Her,

let me have a forceps.

No,

don't 

in all these maneuvers I'm doing now where I'm 

slipping an instrument in.

You've got to be careful not to put pressure down on 

the drum.

You slip it in,

but be careful when you do that you don't.

And when you go to curate the bone off,

I'm prying it off like this.

I'm not doing this with it because you 

could easily touch the 

obstacles and get into trouble.

So I'm actually putting it in here and using it as a 

lever.

Do you see like that?

There we go.

It's fun operation.

It's kind of tricky,

but it's kind of fun to do because it's different,

you know,

new and different type of thing.

See,

here's a case where you have to be very careful 

obstacles,

short processes.

That's bone of obstacle right there.

And you gotta be very careful not to pry on it.

So you can't do the curating the way you 

would normally do it.

That's what I'm doing is not the way you normally cure it.

You don't use a scraping motion,

but that's what you're doing here.

All right.

Now,

let me have the,

let me have a number one knife.

We're making good progress here.

Now,

you can begin to see the drum 

and there's the um bow right there.

See,

okay,

at this point,

we can begin to see how much more we've got to 

do.

You want to get it all off,

within limits weapons?

You don't want to get it all off to the point that when you've 

finished it you've torn the drum.

Well,

let's see how much more we have to go here.

Well,

we've got a fair amount.

You see that fair amount to go there.

Okay.

Roll them,

turn the water down a bit.

I have to stay,

please.

You'll notice I've still left some bone up in there.

That's again,

just so that I don't get into that area too 

closely until I really plan on it.

In other words,

I don't want to get into it by accident.

So I like to go with this slow and easy,

methodically and so forth and just take your 

time because you can really,

you can really get into trouble with these and have a real 

mess on your hands.

If you start,

if you know,

if,

if you're not very careful with them,

they are not easy to do 

another message to that is don't go doing them unless they need 

to be done because these are the interesting thing about these 

patients is as opposed to almost other,

almost any other ear surgery you do.

These patients don't have any trouble,

they don't have any hearing loss,

they don't have a draining ear.

All they have is an ear.

That looks odd.

So you want to make sure they've got trouble,

the warrants doing something and that trouble is 

usually recurrent episodes of Otitis external.

I do keep an eye on some of these and if I've watched 

them and it's obvious they're getting worse and worse and 

worse,

even though they haven't started to have symptoms,

but it's obvious weapon that they are going to have to have it 

done,

then it's a little bit easier to do it before it blocks it this 

much.

But nonetheless,

you don't want to get too eager with these.

They are,

they are cases which are 

fraught with all sorts of difficulties.

I've got a little hematomas on the eardrum.

Things are looking pretty good here.

Inferior.

Well,

we've still got a ledge,

huh?

All right.

Roll the table away some more.

Would you 

let me have the staples,

cure it again,

please?

I can use a fairly good sized Keret here because 

I'm away from the,

um,

bow in our secular chain.

And at this point I'm fairly safe.

It's fairly safe to do.

So.

I mean,

you can do all this work with a drill,

but I guess this just shows my antiquity.

I learned to use a cure it many years ago 

in training and I like to do it.

Let's have the weapon again,

please.

Uh,

we're at the annular ligament right now.

No,

Dr.

Christian will be closing within 15 

minutes.

All right,

we are at the annular ligament there.

We still got a little bone that might be taken off at 

that point.

But let's see now.

Heck no,

you see,

you can see annular ligament already.

You see,

you can see the annual list right there.

Let me show you something here.

Something I was just analyzing.

I think I've got facial nerve exposed in the ear canal.

Let me take a look and see if I do.

It could be.

I saw it when I came on it right here.

Do you see this?

That's facial might as well pointed out 

to you because you don't often see this.

Let me have a,

let me point out what I did.

You remember I said that as I was coming in,

I was coming in a little far back here.

Where do you see that white?

That's facial nerve shows you can get to the 

facial nerve in the ear canal.

You don't see that very often because you don't normally approach 

away.

But that's facial nerve and it shows that the 

facial which is up would normally be lying medial to 

the medial ligament up here is now riding lateral to it on the 

course to the style mastoi.

Huh?

Okay.

We're down to annular ligament there.

We've got a bit up here.

Not a lot.

Let me have a cutting bird next to 

the uh medium.

Now,

what I'm gonna do is I'm gonna use a cutting burr 

lateral to the next smaller 

size.

You see the apex,

the apex of this bone right here.

Right where I'm touching,

I'm gonna use,

I'm gonna work lateral to that.

And that way I know I'm lateral to hospitals and I'm going to thin it 

down with a cutting burr.

Both on.

We're just going to thin this down with a cutting bird 

and create sort of a shell.

The shelf turned the water down just a bit.

The shell protects us from the articles from the 

skin,

from the eardrum.

You see,

the shelf is getting very thin.

In fact,

it's almost cut through at this point.

Now,

let's have a staple cure right now.

We'll take that off like this,

huh?

Okay.

Art.

So at that point that leaves us with a little bit,

we can take off here with the cure and you 

can oftentimes finish it in this portion up here.

Now,

this is the difficult angle to get done is this 

anterior superior angle.

But whereas in our tim panic membrane drafting,

it's important.

It's not here because it's all going to be covered by skin.

You see now,

at this point,

we can also come back here and take off some of 

this right next to the 

All right.

Now,

let me have now a weapon as I think we're near to the 

point where we're gonna be through here.

Let's just take a look,

fold our skin back up,

see where we stand how much we got left 

unfold the skin like this.

Now there's,

there's swelling over the drum and I can't see the 

short process,

but I can feel short processes right there.

We are above the short process.

All right.

Now,

what have we got here?

Well,

we got a little overhang up here,

but this is almost cosmetic from this point on.

I'm gonna just take a little of this off to make it look 

pretty.

I'm gonna cut this flat down to about the 

level of the annual.

It's just so that it will lie flat like that.

Otherwise it would hang up a bit.

You see?

All right,

let me have,

let me have the weapon.

That attorney.

Okay.

Well,

Jerry,

I think we are ready to have some packing right 

now.

Drum looks good.

Now you can tell that there's no hole in the drum because the drum is 

bulging because of his anesthesia.

She just balls right out.

You see it.

And uh,

so that's very helpful.

Normally the anesthesiology is not very helpful in these 

cases,

but he sure is here.

Let's have more and bigger.

Now let me have the other canal skin.

It doesn't look very good,

but it's alright.

Let's have a ring.

Well,

I usually advance it in a bit.

Normally I don't,

normally you're missing an area and I 

leave a little royal external.

Yeah,

between it and the other skin and so forth.

Try to make sure the skin edges are rolled 

out.

All right.

Let's have packing.

Okay.

Roll.

That's fine.

That's good.

I didn't,

I didn't show putting the vascular strip back in place,

but essentially what I did,

I put all the skin back in place and then put the vascular 

strip back in place,

packed the ear with gel foam,

uh with gel foam soaked with some quarter 

spore in solution.

And the postoperative care is to leave all this 

alone for about 10 days.

Then you can aspirated in the office.

And if the year has any drainage problem,

which it sometimes does with granule ations,

I put them on dilute vinegar,

swishes,

half strength white vinegar.

Let me show you a little bit about this matter of the osteo um of the 

ear canal.

This is what it looks like.

Notice that it's normally attached at 

the junction of the outer and middle third of the year 

canal and it presents itself just in this way 

and uh the treatment of its 

relatively simple.

Now,

there have been a number of different ways that have been recommended at 

times to approach problems of the ear canal.

I don't recommend any of these for the most 

part.

But here is one that fact,

in fact depicts what you do.

You don't do it in the office or with a patient standing up,

but you take a little mallet and 

gouge and you tap it and it falls 

off the way you can do that 

is this here shows you a view,

you're looking into the air canal,

you have this podunk,

yah,

lated unilateral osteo MMA 

attached to the Timpano squamous suture.

What you normally do working through the air 

canal,

usually under local anesthesia.

You can pass a hook down deep to this,

take a little gouge,

have your nurse tap it and the thing falls off 

and you can deliver it out the ear easily.

You may want to take a little burr and burnish the base of it.

Now,

this is not what I'm going to show 

you on the tape 

because unfortunately,

I didn't have a tape of this.

But I have a very unusual case.

This is of a doctor and he had a 

solitary osteo more of his ear canal,

but it was attached right next to the short 

process of the malia's.

And on him,

I went in behind the ear doing this post to 

regularly under local.

But I used the same technique finally to get it out.

I passed something deep to it.

I then put a gouge here at this point 

anyway,

tapped it.

And as you'll see,

the osteo MMA fell away very 

nicely.

Let's go to the T V tape.

This,

this patient has a solitary 

osteo Mahy in his left ear canal.

And he's been under the observation of an ear,

nose and throat man for oh 10 years or 

so and his ear gets plugged up occasionally and he's been 

watching the things slowly grow and referred him to me.

He's got mild diffuse exhaust.

Oh sis in both ears canal,

both ear canals.

This is no problem.

This is a solitary osteopath.

The only thing different about it is that solitary osteo Mazar 

normally unilateral as this is the 

only thing different about it is that they're normally in 

the,

at the junction of the outer and middle third and they're usually 

attached to the temple suture line.

This one is quite a bit further immediately than this.

And whereas I might normally go through the ear canal 

here,

I have gone post irregularly.

Now,

prior to the time we started the tape,

I made a post auricular incision,

turned the air forward,

transected the ear canal and now we'll go to the 

microscope and take a look.

Now,

I realize I've transected the ear canal at about the 

junction of the outer and 

middle third.

And this is way down in deep frozen 

needle,

way down in deep.

You can just barely see around it,

but it's quite a bit different in that.

They are normally attached out here at this level and you can 

easily do them trans canal.

Now,

this is not,

And the question only.

So I went post directly on it so that I could get a 

better view of it,

but it's about three quarters,

90% blocked.

So what I'm doing at this point is cutting out the 

vascular strip area.

Now,

one could say,

well,

why didn't you leave it attached to the oracle?

Well,

I didn't because I didn't think it was gonna be 

necessary and it's a very little 

concern but I didn't and we'll excise 

the skin and then just put it back in when we get 

through.

Now,

let me have the,

let me have a weapon,

please.

But Sammy,

you can see this.

It's not a very common place to have one of these.

Usually if you see them,

they're not very common.

They're,

they're right down there in the outer,

there's much more lateral than this 

white players.

Now,

what I'm gonna do let me have a two knife.

We're gonna try to cut across the base of this so that 

we can take this out and not a vault it 

and you can put this aside just as you would canal 

skin,

Jerry,

I get the impression that if I can get it 

loose,

I can get it out.

Now,

I've passed medial to it here,

but I'm not sure I can't feel myself getting 

around it.

So we're gonna drill,

I'm under it here,

but I'm not under a tail.

And as I said to you all this is exactly the reason that 

I wasn't gonna try to approach this from 

through the ear canal because I just did not want to get 

caught short on something.

What I'm gonna do,

I'm gonna take out the skin.

Let's have a # two knife.

I'm gonna take out the skin post eerily down to the 

level of the lesion and 

then I'm gonna drill down some of the bone post clearly to 

see if I can get some room there so I can see 

around it because right now 

I can't see around it.

Let me have a cup forceps.

Alright.

You can put this in with the canal skin,

roll them,

turn the water down a bit,

please.

A little bit more.

That,

that's good right here.

All right off.

Let's go to the next smaller size bird.

Let's have the next smaller size bird.

And hopefully I will keep it from coming loose because 

I don't little more water.

I can keep it from coming loose water.

There we go.

Turn it down a bit.

Keep it from turning down a bit.

There we go.

Keep it from coming loose because if it does,

why it will tend to impact immediately.

But I did and they didn't remark on it to you 

doctor.

I went down below it and hooked under it to see if I 

could move it and it seems pretty solid.

Next,

the next smaller size cutting burr.

Alright.

Roll them.

Now,

at this point with this delicate bird,

I'm actually drilling right at the junction of the two 

because the reason is because I've got into a master 

cell there And I just assume 

not getting more to one.

Alright.

Off.

Let's see.

We'll put this down here like this.

See,

well,

we can get that out from posterior.

Really.

We can pass around the lesion 

and it comes out posterior Lee.

Oh,

I think we're ready to go here now.

I think we're ready to go roll the table away a bit.

Please.

Let's get out the small gouge.

Hold it.

Now,

what I'm gonna do is to pass my hockey stick 

Deep to the lesion.

Let me have a number three Baron deep to the 

lesion.

Get behind it and then just try to tap it loose and 

roll it out.

As long as I would feel that it's not going to 

impact.

You see,

we pass around the lesion and get under it.

All right,

it's under it.

Now,

now let me have the gouge in 

my left hand 

just a minute.

Okay.

Again.

Again,

hold it 

again again,

hold it.

That moved it,

that moved it up.

It's movable.

I may have to drill on that pete uncle.

Let's see.

I'm gonna see if I now here it comes,

it's loose.

See it coming.

Okay.

Okay.

It's loose.

Here it comes.

Okay.

Let me have the hockey stick again.

Okay.

And now we can see the eardrum for the first time 

down this little hole.

That's a good sized one.

Okay.

Let me have a forceps.

Well,

no wonder it had quite a broad attachment.

Look at that.

You see that,

that's a tremendously broad attachment all along 

the suture line.

Well,

I'm happy to say that this doctor 

who had this very unusual osteo my,

I've never seen anything like it.

He got along very nicely.

One thing I didn't show you on the tape because it was of no great 

importance was that he got a little tear in 

the parts flash because of the skin of the osteo.

MMA was actually attached very tightly.

I repaired this with a small under surface graft.

Everything went along very nicely.

I packed his ear with gel foam,

took the gel phone out after about two weeks 

and the ear healed very nicely.

So we've talked about two surgical problems.

One of them very uncommon,

the isolated yoma attached to the 

temple,

the junction of the outer and middle third of the ear canal,

not specifically like the one you just saw,

this is invariably a surgical problem.

The other one is very common problem.

Often in swimmers,

many of my patients are professional lifeguards.

Uh the problem of diffuse 

exhaust.

Oh sis which is bilaterally symmetrical usually 

does not require surgery unless the 

patient is having considerable symptom.

Atala ji from it and it 

can be a difficult operation.

Thanks for watching.