Fisch approaches Dr Zeeshan Ahmad
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Transcript of Fisch approaches Dr Zeeshan Ahmad
Dr Zeeshan Ahmad
M.S.(ENT, PGY3)
Department of ENT, NMCH,
Patna.26.03.2015
Head of the ENT Department of the University
Hospital in Zurich from 1970 to 1999.
At present he is in charge of Otology and Skull
Base Surgery at the ORL-Center of the Klinik
Hirslanden, Zurich.
Published more than 300 articles concerning
Microsurgery of the Middle Ear and the Skull
Base.
He is also author of many books. Two of them,
"Tympanoplasty, Mastoidectomy and Stapes
Surgery" and "Microsurgery of the Skull Base"
are classics in the ENT field.
TYPE A
TYPE B
TYPE C
Type A dissection entails radical
mastoidectomy, anterior transposition of
the facial nerve, exploration of the
posterior infratemporal fossa, and cervical
dissection permitting access to the
jugular bulb,
vertical petrous carotid, and
posterior infratemporal fossa.
Type B dissection explores the
petrous apex,
clivus, and
superior infratemporal fossa.
Type C allows exposure of
the nasopharynx,
peritubal space,
rostral clivus,
parasellar area,
pterygopalatine fossa, and
anterosuperior infratemporal fossa.
Should allow for further extension
Vascularization
Cervical exposure
Anterior extension
Periosteal flap
EAC transection
Undermined
Everted
Sutured
Reinforced
with
periosteal flap
Skin elevated circumferentially
Annulus lifted
incudostapedial joint is separated
Tensor tympani tendon is cut
Neck of the malleus is nipped
Expose the inferior margins of the tumor
Control of vessels
Greater auricular nerve sectioned carefully
Neurovascular structures identified
Posterior belly of Digastric cut
located deep to the midpoint of a line
between the tragal pointer cartilage and
the mastoid tip
In the type B and type C approaches, facial
nerve transposition is not required; only the
frontal branch is followed distally to allow
its preservation when the zygoma is
transected.
Removal of air cell tracts lateral and
adjacent to the otic capsule
Cavity obliteration
Facial nerve skeletonization
Stapes suprastructure removal
Eustachian tube obliteration
Skeletonize
from the geniculate ganglion to the
stylomastoid foramen
LSCC
Digastric ridge
Stylomastoid foramen
new bony canal is drilled in the anterior
wall of the epitympanum to receive the
nerve
Posterior fossa dura anterior and posterior
to the sigmoid sinus
Dura is elevated with dural hooks
incised in front and behind the sigmoid sinus
a blunt-tipped aneurysm needle - ligature
CSF leak managed
Alternatively, intraluminal absorbable
packing
Styloid process is fractured and removed
Parotid dissected off the tympanic bone
Laminectomy retractor for mandible
Facial nerve monitoring
With removal of bone over the carotid
artery and beneath the otic capsule, the
jugular fossa is exposed for tumor removal
After exposure and distal control of the
internal carotid artery are accomplished,
the tumor may be carefully removed.
The jugular vein is ligated to prevent tumor
and air embolism
Dissection begins by freeing the internal
carotid artery and rotating the tumor
posteriorly
The lateral wall of the sigmoid sinus is
removed along with intraluminal tumor
extracranial tumor is removed
If the tumor extends intracranially, it is
amputated sharply at this point
posterior fossa dura is opened, and the
intracranial portion of the tumor is excised
same setting for intracranial tumors smaller
than 2 cm
The dura usually is left with a defect too
large for primary closure - Fascia lata
Abdominal fat - obliterate the dead space of
the temporal bone
Temporalis muscle - rotated inferiorly for
reinforcement of the wound
The skin is closed routinely
The steps up to transposition are identical
to those for the type A approach
transposition of the nerve usually is not
required.
Reflection of the temporalis muscle still
attached to the coronoid process and the
zygoma allows the retractor to expose the
superior infratemporal fossa
The middle meningeal artery - bipolar
cauterization
V3 – transection
The carotid artery may be uncovered from
its vertical segment to its anterior limit at
the foramen lacerum after separation from
the soft tissues around the eustachian tube
Petrous apex lesions, such as
cholesteatoma or
low-grade chondrosarcomas,
removed with careful anterolateral retraction
of the internal carotid artery.
Extensive benign lesions
petrous apex and perilabyrinthine area
require a transotic approach combined with
posterior facial nerve transposition
Exposure of the clivus
obtained by sharp incision of the fibrous
attachments at the petro-occipital fissure.
Tumors of the clivus, such as chordomas, up
to the parasellar area may be removed
through the type B approach
Removal of the mandibular condyle may
give better exposure to the inferior clivus
and upper cervical vertebrae
Anterior extension of type B
Permits posterolateral access to the
rostral clivus,
cavernous sinus,
sphenoid sinus,
peritubal space,
pterygopalatine fossa, and
nasopharynx and
to the areas exposed by the type B
approach
The base of the pterygoid process is
removed to approach the sphenoid sinus and
cavernous sinus
Removal of the pterygoid base uncovers V2
in the foramen rotundum and the inferior
orbital fissure.
The cavernous sinus is exposed by thinning
the bone of the middle cranial fossa floor
anterior to the V2 stump.
To enter the lateral nasopharyngeal cavity,
the lateral and medial pterygoid processes
are removed, and the buccopharyngeal
fascia and nasopharyngeal mucosa are
incised.
Separation of the pterygoid muscles from
the mandible allows en bloc removal of the
lateral nasopharyngeal wall, peritubal
space, and superior infratemporal contents
when needed for tumor extirpation
The infratemporal fossa approach, in
conjunction with the application of
microsurgical technique and improved
perioperative care, has permitted
significant advances in lateral skull base
surgery.
The glomus jugular tumor is the
prototypical neoplasm resected by this
approach, although this technique can be
applied to a host of additional benign and
malignant lesions of the skull base.
02.04.15 Dr Sonu Kr
SinghM.S.(ENT,PGY3)
Cochlear Implantation –
Candidacy and
Postoperative
rehabilitation