Mount Sinai neurotologists routinely work with plastic surgeons to treat patients with craniofacial abnormalities including microtia and ear canal atresia (lack of ear canal). In addition to the cosmetic deformity associated with microtia, patients often have significant conductive hearing loss and malformations of their ossicles, or hearing bones located behind the tympanic membrane (Ear drum). Neurotologists may make a new ear canal as shown in this video or treat the conductive hearing loss with what is known as a bone conduction hearing implant/hearing aid such as the Cochlear BAHA Connect, Med El BONEBRIDGE, or Cochlear OSIA. Surgery is typically done on an outpatient basis and patients go home the same day.
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George Wanna, MD, FACSChair of Otolaryngology – Head and Neck Surgery New York Eye and Ear Infirmary of Mount Sinai and Mount Sinai Beth Israel Chief, Division of Otology-Neurotology Mount Sinai Health System Professor of Otolaryngology, and Neurosurgery Icahn School of Medicine at Mount Sinai
Maura K. Cosetti, MDDirector, Ear Institute at New York Eye and Ear Infirmary (NYEE) of Mount Sinai Director, Cochlear Implant Program Mount Sinai Health System
Enrique R. Perez, MD, MBADirector of Otology-Neurotology The Mount Sinai Hospital Assistant Professor, Otolaryngology Mount Sinai Health System
Zachary G. Schwam, MD Assistant Professor, Department of Otolaryngology-Head and Neck Surgery Division of Otology-Neurotology, Lateral Skull Base Surgery Mount Sinai Health System The Mount Sinai Oology Surgical video series presents ear canal reconstruction for congenital oral atresia, also known as Atreo Plasty. This procedure is performed by our division neurotologist for Children and adults to rebuild a new ear canal often in the setting of concomitant microtia. This video was edited by Zachary Swan. We begin with a post irregular incision. The mastoid tip is marked with an arrow, we incise through the skin and subcutaneous tissue, identifying the post irregular muscle which is divided. This plane is then taken superiorly to the level of the temporo parietal fas, a large temporoparietal fas graft is harvested, outlining the border with a knife and finishing the harvest with a curved scissor. The true temporalis fash is left down a periosteal or PVI flap is then made with a Bovi. A backward seven incision is made down to the level of bone. It is then elevated with a leopard periosteal elevator. The purple circle marks the anticipated location of the new canal which is sandwiched between the tag or middle fossa floor and the temporomandibular joint or T M J. It is important to use these two landmarks. We begin by drilling within the confines of the purple circle with a large cutting burr, we will try to identify the segment first. After a bit of drilling, we fall into the Antrim. Now that we're a little better oriented, we have to redirect a bit anteroinferior. As marked by the turquoise arrow. We accelerate more bone until we identify the atretic plate. The shadow of the Acular mass can be seen at the posterior aspect of it. The superior aspect of the plate is drilled off carefully until we fall into the tympanum. This diagram shows the ocular mass obscured by the atretic plate as well as the anticipated course of the facial nerve in yellow. In atresia cases, the facial nerve is usually quite close to the ocular mass as it turns at approximately eight o'clock. The normal course of the nerve is outlined in blue. The atretic plate is sequentially drilled until it is paper thin once very thin, a right angle hook is used to gently remove the bone. At this point, we can see the start of a relatively well formed articular mass with malleus head in his body. And in his short process, we still have to remove the anterior and inferior aspects of the atretic plate. This is done. So with a diamond drill, we are very careful inferiorly. As we know, the facial nerve can come quite close. The bony flecks are again removed with various instruments. More of the ossicular chain comes into view. The last of the atretic plate is removed with a small diamond burr. So as not to drill on the Acular chain and cause a sensory neural hearing loss. We follow the perimeter with a 1.0 and subsequently 0.5 millimeter diamond drill. Once we clear the perimeter, the chain starts to move. Zooming out, we verify the relationship with the Acular mass to the Tagment and T M J. It is right where we expected it right between the stapes and lateral semi circular canal. The facial nerve is clearly visible. We then ballpark the size of our skin graft, circumference and length with a ruler. We harvest the split thickness, skin graft from the thigh. We then shape it where the purple circle will sit over our fas graft and the sides will fold into a tube to line the bony ear canal. We then turn our attention to the metas. This is a different year from the introductory slide. We mark out anteriorly based tragal skin flap. The incisions are made with a scalpel and the skin is elevated off the underlying soft tissue. Next, we flip the ear forward again and split the periosteal flap. As shown as we can see, there's quite a bit of soft tissue that needs to be resected so that we can get to our new bony ear canal. The soft tissue is circumferentially resected with scissors to make sure the soft tissue opening is adequately sized. We place a finger through the soft tissue meatus, we then put some gel foam around the ossicular chain to help hold up the fasher graft. The fasher graft is then brought in and placed on the ocular chain. The edges of the graft overlap with the bony canal. The skin graft is then slowly brought in and the purple circle is laid on top of the fasher graft. The rest of the graft is placed around the perimeter of the bony canal. A ST Silastic disk is then placed on top of where the aar mass and fash graft are Silastic strips are used to line the canal as well. So that when the mirror cell wicks are removed in the office, we do not pull out the grafts. Several marisol strips are then placed and hydrated. We then tack the PVI flap to the surrounding periosteum. A pickup is used to grab the lateral aspect of the skin graft and pull it through so that it can be sutured to the skin of the meatus. The post iri incision is then closed so that the oracle is in its final position when securing the skin graft. Our anteriorly based tragal skin flap is sewn to the underlying periosteum superiorly and then inferiorly, the skin graft is then sewn to the skin of the oracle. We then put a roll of quarter inch gauze packing to help stent the meat open