65
1 Secrets to Success in Secrets to Success in Tympanomastoid Tympanomastoid surgeries. surgeries. Dr. Prahlada N B, Dr. Prahlada N B, MBBS, MS (PGIMER, Chandigarh) MBBS, MS (PGIMER, Chandigarh) Karnataka ENT Hospital & Research Karnataka ENT Hospital & Research Center, Center, Chitradurga, Karnataka, India. Chitradurga, Karnataka, India. Skip Introduction

Secrets of success in Tympanomastoid surgeries

Embed Size (px)

DESCRIPTION

This is a motivational and scientific presentation related to Tympanomastoid Surgeries in Otorhinolaryngology. This presentation is prepared to motivate junior colleagues to take up Otology (Medical Science related to Ear disease), learn and excel in the same for the benefit of the humanity suffering from Ear diseases. This presentation mainly addresses the basic concepts in commonly performed Micro-Ear surgeries like Myringoplasty, Tympanoplasty, Cortical mastoidectomy and Canaloplasty. The author has used management principles like Total Quality Management, Six Sigma and SWOT analysis to improve quality of the care provided to patients.

Citation preview

Page 1: Secrets of success in Tympanomastoid surgeries

11

Secrets to Success in Secrets to Success in Tympanomastoid surgeries.Tympanomastoid surgeries.

Dr. Prahlada N B, Dr. Prahlada N B, MBBS, MS (PGIMER, MBBS, MS (PGIMER, Chandigarh)Chandigarh)

Karnataka ENT Hospital & Research Karnataka ENT Hospital & Research Center, Center,

Chitradurga, Karnataka, India.Chitradurga, Karnataka, India.

Skip Introduction

Dr.Prahalad
Hi Everybody. This is Dr. Prahlada N.B Talking to you. Hearty greetings to you from Karnataka ENT Hospital and Research Center, Chitradurga, Karnataka State. I dedicate this motivational presentation to the Rotary International, which celebrated its Centennial in 2005. It is Rotary International which provided me an opportunity to conduct free Ear Surgical Camps for poor and needy patients in India as well as Zimbabwe and Sri Lanka and perform more than 4000 Micro Ear Surgeries.
Page 2: Secrets of success in Tympanomastoid surgeries

22

Dedicated to,Dedicated to,

Dr.Prahalad
I dedicate this motivational presentation to the Rotary International, which celebrated its Centennial in 2005. It is Rotary International which provided me an opportunity to conduct free Ear Surgical Camps for poor and needy patients in India as well as Zimbabwe and Sri Lanka and perform more than 4000 Micro Ear Surgeries.
Page 3: Secrets of success in Tympanomastoid surgeries

33

Page 4: Secrets of success in Tympanomastoid surgeries

44

I am no Guru!I am no Guru!

First of all let me make it clear, First of all let me make it clear, I am no Guru!I am no Guru!

Everyone is capable of lot of thingsEveryone is capable of lot of things You are a treasure trove of You are a treasure trove of

knowledge, skill and ideas knowledge, skill and ideas You just have to wake up the Genius You just have to wake up the Genius

within you!within you! I am only trying to un-ravel the I am only trying to un-ravel the

potential within you!potential within you!

Page 5: Secrets of success in Tympanomastoid surgeries

55

First Do No Harm

Making of a Neurosurgeon

Story of Dr. Kenyon Rainer

To begin with, I would like to talk to you about three books which motivated me to become what I am today. Even today they constantly inspire me to achieve something. Keepin ourselves everyday is a big difficult task and these have succeeded in motivating me. I strongly recommend everyone who is interested to succeed, to read these books. Buy them if possible and keep them your bed side and read a page or two almost every day. I read these books whenever I fail in something or whenever I feel down and out or depressed. They have never failed to lift my spirit. The first book is an Autobiography of Dr. Benjamin Carson, MD. One day he was a goon on the streets of notorious Bronx area in New York city. One day he realized his mistake and changed his course of his life, and today he happens to be one of the best Pediatric Neurosurgeon in the world. Recently he was in India, at Apollo Indraprastha Hospital, New Delhi to perform a rare surgery of separating Siamese Twins. How did he achieve that ? Read that marvelous story of struggle of a Black American who transformed himself from a thug to a finest Pediatric Neurosurgeon. The Second book, another Autobiography, of a famous Neurosurgeon, Dr. Kenyon Rainer. Rather, this was the first book I read during my under-graduation. This book speaks about importance of dedication, commitment and endurance required during residency or postgraduate training programs. A must read for all post-graduates and junior surgeons. The third book which inspired me maximum was IACOCCA, an Autobiography by Lee Iacocca. One day Mr. Lee Iacocca was a President of Ford Motors and becomes more popular than Henry Ford himself. He gets fired by the jealous Henry Ford and after that, at the age of 55 years he is jobless and on the streets. He takes over as the President of Chrysler Company which is near bankruptcy. He makes it No.1 in record 3 years. Another, great captivating and motivating story. A must read for everyone. Whenever you are down and out or end up with some complication, read this book. This book will never fail to lift your spirit.
Page 6: Secrets of success in Tympanomastoid surgeries

66

Problem in IndiaProblem in India

7% of Indians have Ear Problems7% of Indians have Ear Problems 90% of these are Middle ear infection90% of these are Middle ear infection 35% have bilateral problems35% have bilateral problems 11 Crore ears need tympanoplasty !11 Crore ears need tympanoplasty ! 22,000 Cases/ENT Surgeon22,000 Cases/ENT Surgeon

Coming to the magnitude of Ear problems in India, 7% of general Indian population has some ear problem which ultimately leads to deafness. Of these, nearly 90% of patients have middle ear infections, and you are aware life threatening complications of middle ear infections are still high in India. According to our experience, about 35% of these patients have bilateral middle ear infections. If we take our present population into consideration, that is awesome 11 Crore ears have ear problems. That means, even if all ENT Surgeons in India perform Micro Ear Surgeries, each surgeon will get to do nearly 22,000 surgeries. That is one big market with great potential to earn lot of money and at the same time help lot of people with such problems.
Page 7: Secrets of success in Tympanomastoid surgeries

77

Hard work is the shortcut to Hard work is the shortcut to success!success!

I hope you all know him. He is none other than the founder and Mentor of Infosys, Mr. Narayana Murthy. Infosys happens to be the first Indian company to get listed on NASDAQ. He made western world aware of Indian brains. Recently he was at IIM, Ahamedabad, interacting with management students. One of the students asked him, how could he achieve his success. He said, "Very simple, by sheer hard work". So it all takes one to achieve what he wants is simple hard work. Friends let me make it clear for you. There is no short cut for success. If you want to succeed, you need to work hard!
Page 8: Secrets of success in Tympanomastoid surgeries

88

SuccessSuccess What makes a person What makes a person

successfulsuccessful How do we recognize How do we recognize

successsuccess To some people success To some people success

means “means “– Wealth, Recognition, Good Wealth, Recognition, Good

Health, Good family, Health, Good family, Happiness, Satisfaction, Happiness, Satisfaction, Peace of Mind.Peace of Mind.

““Success is Success is subjective”subjective”

At the juncture I would like to speak to you few words about success. Ask some one, What is success ? What is the definition of the success ? What makes a person successful ? How do we recognize success? What answers you will get. To some people success means, wealth, recognition, Good health, Good family, happiness, satisfaction, peace of mind. It varies from person to person, but most of the times, it is the success is subjective. . See the picture, which is in the background. For a golfer, just putting the ball into the pit or tee is success.
Page 9: Secrets of success in Tympanomastoid surgeries

99

Success is the Progressive Realization of a Worthy GoalSuccess is the Progressive Realization of a Worthy Goal

Earl NightingaleEarl Nightingale

“Success is the progressive realization of a worthy goal.”

Earl Nightingale

One best definition I have come across is "Success is a progressive realization of a worthy goal". Given by an American teacher, Earl Nightingale. See the picture in the background. A century ago, no human beings ever imagined that, a man could fly like a bird. But it is Wright brothers in 1905 proved that one could fly. Man not only flew, he even landed on the moon. From a simple glider, we progressed to jets, jumbo jets, concords and then rockets. This is true representation of a success, which was progressive realization of a worthy goal.
Page 10: Secrets of success in Tympanomastoid surgeries

1010

Success is a journey, not a Success is a journey, not a destinationdestination

We never arriveWe never arrive After we reach one goal, we go After we reach one goal, we go

on to the next and the next and on to the next and the next and the…….. the…….. ………………………………………………………………………………

““Progressive”Progressive”

Let us analyze this definition little more. Success is progressive. That means, success is a journey, not a destination. We never arrive. After we reach one goal, we go on to the next, and the next, and the next...., What does a mountaineer do? After he climbs one mountain, he climbs the next one. And the next one. Next one....,
Page 11: Secrets of success in Tympanomastoid surgeries

1111

GoalsGoals

Goals are a mustGoals are a must Goals give you direction for your lifeGoals give you direction for your life Life without goals is like a boat Life without goals is like a boat

without a sailorwithout a sailor When you make goals, make big When you make goals, make big

goalsgoals Write down your goals and read Write down your goals and read

them out aloud everydaythem out aloud everyday

Page 12: Secrets of success in Tympanomastoid surgeries

1212

S.M.A.R.T GOALSS.M.A.R.T GOALS

SSPECIFICPECIFIC

MMEASURABLEASURABLEE

AACHEIVABLECHEIVABLE

RREALISTICEALISTIC

TTIME BOUNDIME BOUND

One must have goal. Not having goal is like a boat without the sailor. Make a goal today and when make a goal, make it quite big. Your goals should be worthy. What is a worthy goal. We call them SMART goals. This is a mnemonic and each letter stands for an important word. S stands for Specific. You goal should be specific. You cannot slog on for the something which is vague. My goal was to master middle ear surgeries in one year. M stands for Measurable. You need a yard to stick to measure your progress. Results of your surgeries is a best yard stick.A stands for Achievable. Do not put your hands on something which is not achievable. R stands for Realistic. Your goals should be realistic. Do not ask for moon. T stands for Time bound. You should clear time frame for your goals. You cannot go on working for something for ever and ever.
Page 13: Secrets of success in Tympanomastoid surgeries

1313

MBOMBO

Cost effectiveCost effective Time savingTime saving Maximum resultsMaximum results Least number of complicationsLeast number of complications

TQM – TOTAL QUALITY TQM – TOTAL QUALITY MANAGEMENTMANAGEMENT

Dr.Prahalad
When we speak of goals in our context, i.e,, we surgeons point of view, our goals should be to Master Surgeries. How to define that? We can put it in the words of Management people i.e., MOB or Management by Objective. You should have clear objectives in your goals. Your surgeries should be :Cost effective, Take minimum possible time, Easily reproducible, Provide you maximum results and are Associated with minimum number of complications. We can also put this in other words, i.e., TQM or Total Quality Management, another popular word in Management circles.
Page 14: Secrets of success in Tympanomastoid surgeries

1414

SWOT AnalysisSWOT Analysis

Dr.Prahalad
Next question is how to go about it. There is something called SWOT analysis. S - Strength, W - Weakness, O - Opportunity and T – Threat.This term is being used commonly by marketing executives. This applies to us also. Find out what are your strengths and weaknesses. Then find out what opportunity and threat exist in the world around you. Make use of your strengths to develop you surgical skills and fight your weakness. Make use of all the opportunities exist around you and fight all the threats. I am sure in the end you will be a successful surgeon.
Page 15: Secrets of success in Tympanomastoid surgeries

1515

SWOT AnalysisSWOT Analysis

Dr.Prahalad
A SWOT analysis of a surgeon may be like this. STREANGTHSTraining at a premier instituteSurgical exposureExclusive access to patientsExisting full fledged set upAptitude to learnLocation of businessCost advantageStrong brand or reputationQuality controlNo CompetitionWEAKNESSLack of TrainingLack of Surgical ExposureNo access to patientsNo equipmentNo access to recent advancesLocation of businessNo reputationNo qualityCannot competeOPPORTUNITIESSurgical exposureAccess patientsAccess to set upAccess to recent advancesLearningRelocationControl qualityCompetitionTHREATSFailing to UpdateFailing to LearnRelocationNo Quality ControlNew CompetitorsI strongly advocate every junior surgeon to make a SWOT analysis.
Page 16: Secrets of success in Tympanomastoid surgeries

1616

TQM - Six SigmaTQM - Six Sigma

Dr.Prahalad
I would like to stress about another management terminology here. That is SIX SIGMA. Six sigma advocates DMAIC. That is Define, Measure, Analyze, Improve, and Control. This is the essence of Total Quality Management. When you have a problem at your hand, define it, measure the extent of the problem, analyze and fix it. Once you fix it improve upon it and once you have reached a stage which provides you good results, control it. The total situation should be totally under your control. Practice six sigma. Read more about it.
Page 17: Secrets of success in Tympanomastoid surgeries

1717

11 Steps to success11 Steps to success

ImportantImportant InterdependentInterdependent Complemnentary to each otherComplemnentary to each other

Dr.Prahalad
Each step is important. Each step is interdependent on others. Each step is complimentary for other step. See the picture, how each ball is dependent on other.
Page 18: Secrets of success in Tympanomastoid surgeries

1818

Learn The Kaizen WayLearn The Kaizen Way

Dr.Prahalad
How do we learn these surgical steps. I strongly believe that surgeries cannot be learnt in one single day. I would like to introduce a Japanese term at this moment. It is called "Kaizen". That means "Daily progressive improvement". A big journey starts with a one single small step. But that one small step can change your life. You need to improve every day to master the surgeries. We need to work hard and practice very hard to master the surgeries. I also strongly recommend you to read "The Kaizen Way - One small step can change your life" by Robert Maurer PhD.
Page 19: Secrets of success in Tympanomastoid surgeries

1919

Practice makes man perfectPractice makes man perfect

Dr.Prahalad
It is often said, "Practice makes man perfect". We have learnt during our Ist MBBS from Physiology about Povlolv's experiment on dogs about conditioned reflexes. Practice helps us to develop these conditioned reflexes like Povlov's dogs.
Page 20: Secrets of success in Tympanomastoid surgeries

2020

Dr.Prahalad
See this picture. See the hard working brave warrior and his slave the horse, which is again equally hard working. But what is the difference between the horse and the warrior, I mean in other words, what is the difference between the man and the animal. It is the power of "REASONING". Man has extraordinary capacity of reasoning. When we practice, we develop conditioned reflexes which know reasoning. We need to remember this word reasoning always. While doing surgeries or treating our patients, we should know the reason behind our every single act. That is the key to success and positive results.
Page 21: Secrets of success in Tympanomastoid surgeries

2121

Ask Ask

If you don’t know, Ask !If you don’t know, Ask ! If you are unsatisfied, Ask !If you are unsatisfied, Ask ! If you want to accomplish a goal, Ask !If you want to accomplish a goal, Ask ! If you are confused, for good counsel, If you are confused, for good counsel,

Ask !Ask ! If you desire to communicate, Ask !If you desire to communicate, Ask ! When you expect good things in life, When you expect good things in life,

Ask !Ask !

Dr.Prahalad
Read this quote, which is very important. Being curious, inquisitive or doubting Tom will always help you on the long run. While on the success path you will get opportunity to listen many lectures, watch many surgical demonstrations and read books written by the best of surgeons. But, never accept anything blindly. Always clarify your doubts. Your power of reasoning. Whatever we do has a scientific base. Understand the basics of our science. Always ask and clear your doubts. Remember the following words always. If you don’t know, Ask!If you are unsatisfied, Ask!If you want to accomplish a goal, Ask!If you are confused, for good counsel, Ask!If you desire to communicate, Ask!When you expect good things from life, Ask!
Page 22: Secrets of success in Tympanomastoid surgeries

2222

Step 1 :Step 1 : Selection of CasesSelection of Cases

Know when not to operate : Know when not to operate :

“Many times, to realize on which “Many times, to realize on which patients one should not operate is what patients one should not operate is what makes a surgeon’s final results shine makes a surgeon’s final results shine

above those of others”.above those of others”.

Hamed Sajjadi, MD, FACS.Hamed Sajjadi, MD, FACS.OTOLARYNGOLOGIC CLINICS OF NORTH OTOLARYNGOLOGIC CLINICS OF NORTH

AMERICAAMERICA

Volume 32. Number 3. June 1999.Volume 32. Number 3. June 1999.

Dr.Prahalad
Step 1 : Selection of Cases. I would like to put it in other words, i.e., "Knowing when not to operate". This is more important. A great otolaryngologyist, Hamed Sajjadi , MD, FACS, has said in his article published in OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA, Volume 32. Number 3. June 1999, "Many times, to realize on which patients one should not operate is what makes a surgeon's final results shine above those of others'. One should select cases properly and should know when and which cases not to operate.
Page 23: Secrets of success in Tympanomastoid surgeries

2323

Step 2 :Step 2 : Good AnesthesiaGood Anesthesia

Use GA/LA judiciously. Use GA/LA judiciously. Don’t be Don’t be dogmatic.dogmatic.

Infiltrate LAInfiltrate LA even when you operate even when you operate under GA.under GA.

Variation of anesthetists.Variation of anesthetists.– Superficial typeSuperficial type– Gas manGas man– Freelancer Freelancer

Dr.Prahalad
Step 2 : Using good anesthesia. Either GA or LA can be used for Micro ear surgeries, don't be dogmatic about any one particular type of anesthesia. Use the type of anesthesia judiciously. The patient and circumstances should choose the type of anesthesia rather than the surgeon. Even when surgery is done under General anesthesia, give a good local anesthesia infiltration. This is very important to provide complete analgesia to the patient. If there is no analgesia, the pain activates adrenalin mechanism and cause more bleeding. Bleeding interferes with a good middle ear work. The choice of drugs used and plane of anesthesia varies from anesthetist to anesthetist. With my 10 years of experience with anesthetists, I divide them into three groups. 1. Superficial type, 2. Gas Man and 3. Free lancer. 1. Superficial type : These anesthetists always keep plane of anesthesia superficial for fear of risks. In such situation there will not be complete analgesia and patients are likely to have more bleeding. 2. The Gas Man : These anesthetists use lot of anesthetic gases, which often causes of vasodilatation and in turn excessive bleeding. 3. Free lancers : These people are always on the run and are always in hurry. Even before you complete the suturing patients is already up and moving. This can interfere with your work.A good local infiltration shall counter all these situations. One should practice good local infiltration techniques for micro-ear surgeries.
Page 24: Secrets of success in Tympanomastoid surgeries

2424

Bevel of the needle should be Bevel of the needle should be towards the bone.towards the bone.

VideoVideo Click video button below. Click video button below. And click play button in Quite time movie And click play button in Quite time movie

player.player. Open movie file anesthesia with Quick Time Open movie file anesthesia with Quick Time

Movie Player. Movie Player.

Dr.Prahalad
While giving the local infiltration the bevel of the needle should be towards the bone. If not the anesthetic injects escapes and is not well deposited. Sometimes it may lead to bleb formation.
Page 25: Secrets of success in Tympanomastoid surgeries

2525

Page 26: Secrets of success in Tympanomastoid surgeries

2626

Step 3 :Step 3 : Approach/TechniqueApproach/Technique

““Every intra-op surgical decision needs to Every intra-op surgical decision needs to be custom-made to the individual patient’s be custom-made to the individual patient’s needs and the surgeon’s capabilities and needs and the surgeon’s capabilities and facilities. facilities.

Surgeon’s must avoid fitting their patients Surgeon’s must avoid fitting their patients to their surgical techniques. to their surgical techniques.

On the contrary, we must adjust our On the contrary, we must adjust our surgical choices to fit each patient's surgical choices to fit each patient's situation needs. “situation needs. “

Dr.Prahalad
Step 3 : Approach. Even though the tympanoplasty can be done through trans-canal, end-aural or post-aural approaches, one should use the approach according to the situation. “Every intra-op surgical decision needs to be custom-made to the individual patient’s needs and the surgeon’s capabilities and facilities. Surgeon’s must avoid fitting their patients to their surgical techniques. On the contrary, we must adjust our surgical choices to fit each patient’s situation needs.
Page 27: Secrets of success in Tympanomastoid surgeries

2727

Step 3 :Step 3 : Approach/TechniqueApproach/Technique

Multiple choices may have to be Multiple choices may have to be considered before each patient is considered before each patient is offered a particular type of surgery, offered a particular type of surgery, and surgeons need to be prepared to and surgeons need to be prepared to change their techniques accordingly change their techniques accordingly and competently. and competently.

Hamed Sajjadi, MD, FACS.Hamed Sajjadi, MD, FACS.OTOLARYNGOLOGIC CLINICS OF NORTH AMERICAOTOLARYNGOLOGIC CLINICS OF NORTH AMERICAVolume 32. Number 3. June 1999. Volume 32. Number 3. June 1999.

Dr.Prahalad
Multiple choices may have to be considered before each patient is offered a particular type of surgery, and surgeons need to be prepared to change their techniques accordingly and competently. “
Page 28: Secrets of success in Tympanomastoid surgeries

2828

Step 3 :Step 3 : Approach/TechniqueApproach/Technique

TranscanalTranscanal EndomeatalEndomeatal End-auralEnd-aural Post-auralPost-aural

Dr.Prahalad
Various approaches at our disposal are: 1. Trans-canal2. Endo-meatal3. End-aural4. Post-aural
Page 29: Secrets of success in Tympanomastoid surgeries

2929

How I do itHow I do it

Trans-canal approachTrans-canal approach– Post-traumatic perforation - < 3 monthsPost-traumatic perforation - < 3 months

Dr.Prahalad
1. Trans-canal approach: I use this approach in cases of Post-traumatic traumatic perforations of less than 3 months duration.
Page 30: Secrets of success in Tympanomastoid surgeries

3030

How I do itHow I do it

Endomeatal approach – Wide canalEndomeatal approach – Wide canal– Post-traumatic perforation - > 3 monthsPost-traumatic perforation - > 3 months– Central perforation – other aetiologyCentral perforation – other aetiology– < 3 months.< 3 months.

Dr.Prahalad
2. Endo-meatal approach – This approach is used in cases with Wide external auditory canala. Traumatic perforation - > 3 months.b. Central Perforation of any other etiology - 3 months duration.
Page 31: Secrets of success in Tympanomastoid surgeries

3131

How I do itHow I do it

End-aural approach – Narrow CanalEnd-aural approach – Narrow Canal– Posterior Central perforationPosterior Central perforation– When Cortical mastoidectomy is not When Cortical mastoidectomy is not

plannedplanned

Dr.Prahalad
3. End-aural approach – This approach is used in patients with Narrow Canal, particularly in cases with:a. Posterior Central Perforationb. When Cortical Mastoidectomy is not planned.
Page 32: Secrets of success in Tympanomastoid surgeries

3232

How I do itHow I do it

End-aural incsions for Koerner’s End-aural incsions for Koerner’s flap/Post-aural approachflap/Post-aural approach– Anterior perforation/Anterior bony Anterior perforation/Anterior bony

overhangoverhang– Large perforation/Subtotal/total Large perforation/Subtotal/total

perofrationsperofrations– When Cortical mastoidectomy is When Cortical mastoidectomy is

contemplatedcontemplated

Dr.Prahalad
4. Post-aural approach in combination with End-arual incisions for Koerner's Flap is used in: a. Anterior perforations.b. Anterior bony overhang is present.c. Large perforations/Subtotal or total perforations.d. When Cortical Mastoidectomy is contemplated.
Page 33: Secrets of success in Tympanomastoid surgeries

3333

Step 4 :Step 4 : Incision TechniquesIncision Techniques

End-aural incisionsEnd-aural incisions VideoVideo Watch “approach” video with Quick Watch “approach” video with Quick

Time Movie Player. Time Movie Player.

Dr.Prahalad
Step 4: End-aural incisions. Here I would like to elaborate little bit on Lempert's end-aural incision, which are either used as a sole approach in Endaural approach. Or in combination with Post-aural approach in Combined end-aural and post-aural approach. The proper technique of Lempert's end-aural incision is crucial for elevating a proper Koerner's and tympanometal flaps. This is crucial step because the skin of the external auditory canal is like 24 carat gold and we need to preserve every millimeter of it. It is the skin of the external auditory canal which provides the graft the much needed stability, blood supply and epithelialization and therefore it must be preserved at any cost.
Page 34: Secrets of success in Tympanomastoid surgeries

3434

Making End-aural incisions.Making End-aural incisions.

The Modified Lempert's end-aural The Modified Lempert's end-aural incision consists of 3 parts. incision consists of 3 parts. – Part 1 : Posterior canal wall incision.Part 1 : Posterior canal wall incision.– Part 2 : Superior canal wall incision.Part 2 : Superior canal wall incision.– Part 3 : Inferior canal wall or floor Part 3 : Inferior canal wall or floor

incision.incision.

Dr.Prahalad
The Modified Lempert's end-aural incision consists of 3 parts. Part 1 : Posterior canal wall incision.Part 2 : Superior canal wall incision.Part 3 : Inferior canal wall or floor incision.
Page 35: Secrets of success in Tympanomastoid surgeries

3535

Making End-aural incisions.Making End-aural incisions.

Part I : Posterior canal wall incision.Part I : Posterior canal wall incision.

Dr.Prahalad
End-aural incision techniquesPart 1: Posterior canal wall incision. This is an horizontal incision on the posterior wall of the external auditory canal, about 5 mm away from the annulus. The starting point of the incision is at 12 'O' clock position of the roof or superior wall of the external auditory canal to the 6 'O' Clock position on the floor of the external auditory canal.This incision is preferably made with Rosen's knife. The incision should be bone deep and while making the incision one should feel the bone. All the fibers of the skin and periosteum should be cut through and through and the bone of the external auditory should be visible through the incision. Pic 1: Shows microscopic view of the external auditory canal where Part 1 incision is being made using a Rosen's knife. Pic 2: Shows saggital section of the external auditory canal where Part 1 incision is being made using a Rosen's knife.
Page 36: Secrets of success in Tympanomastoid surgeries

3636

Making End-aural incisions.Making End-aural incisions.

Part 2 : Superior Canal Wall incision.Part 2 : Superior Canal Wall incision.

Dr.Prahalad
Part 2: Superior canal wall incision. This is a vertical incision starting at the 12 "O" clock on the superior wall where earlier Part 1 incision started. The incision courses outside the point between the tragus and the origin of the auricle. This incision is made preferably with a No. 15 Bark Parker's knife. Again the incision should be bone deep and while making the incision one should feel the bone. All the fibers of the skin and periosteum should be cut through and through and the bone of the external auditory should be visible through the incision. Avoid cutting the Conchal cartilage to avoid the risk of perichondritis. Particular attention should be given to the junction where the Part 1 incision meets the Part 2 incision. It is here sometimes the fibers of periosteum may remain uncut and pose challenge when one tries raise the Modified Koenrer's flap. It may result in flap tear of tympanomeatal flap or Koerner's flap. Pic 1 : Shows microscopic view of the external auditory canal where Lempert’s Part 2 incision is being made using a No. 15 Bard Parker's knife. Pic 2 : Shows Coronal section of the external auditory canal where both Part 1 and Part 2 incision are being shown.
Page 37: Secrets of success in Tympanomastoid surgeries

3737

Making End-aural incisions.Making End-aural incisions.

Part 3 : Inferior Canal Wall or floor Part 3 : Inferior Canal Wall or floor incision.incision.

Dr.Prahalad
Part 3 : Inferior canal wall or floor incision. This is again a vertical incision starting at the 6 "O" clock on the inferior of the external auditory canal where earlier Part 1 incsion ended. The incision courses outside or lateral far about 2-3 mm on the floor or inferior wall of the external auditory canal. This incision is made preferably with a No. 15 Bark Parker's knife. Again the incision should be bone deep and while making the incision one should feel the bone. All the fibers of the skin and periosteum should be cut through and through and the bone of the external auditory should be visible through the incision. Avoid cutting the Conchal cartilage to avoid the risk of perichondritis. Particular attention should be given to the junction where the Part 1 incision meets the Part 3 incision. It is here sometimes the fibers of periosteum may remain uncut and pose challenge when one tries rise the Modified Koenrer's flap. It may result in flap tear of tympanomeatal flap or Koerner's flap. Pic 1 : Shows microscopic view of the external auditory canal where Part 3 incision is being made using a No. 15 Bark Parker's knife.
Page 38: Secrets of success in Tympanomastoid surgeries

3838

Making End-aural incisions.Making End-aural incisions.

Page 39: Secrets of success in Tympanomastoid surgeries

3939

Making End-aural incisions.Making End-aural incisions.

Dr.Prahalad
Pic 1 : Shows microscopic view of the external auditory canal where Lempert’s Part 2 incision is being made using a No. 15 Bard Parker's knife. Pic 2 : Shows Coronal section of the external auditory canal where both Part 1 and Part incision are being shown.
Page 40: Secrets of success in Tympanomastoid surgeries

4040

All that we need is a All that we need is a winning edgewinning edge

PrecisionPrecision

Dr.Prahalad
One word of caution at this moment. Precision of landmarks and execution of surgical step is of paramount importance while making end-aural incision. See the picture in the back ground, which is depicting the sprinters. Now days in Olympics, the 100 meter sprint race is so competitive, the results are decided on photo finish. It is such win on photo finish is what we need. This applies to our surgical steps also. All that we need is a winning edge.
Page 41: Secrets of success in Tympanomastoid surgeries

4141

Step 6 :Step 6 : CanalplastyCanalplasty

To remove bony overhangTo remove bony overhang Post-op examination easyPost-op examination easy Helps graft uptakeHelps graft uptake Improves hearingImproves hearing Reduces post-op Reduces post-op

infections/otomycosisinfections/otomycosis

Dr.Prahalad
Step 6 : Is Making canalplasty. Canalplasty is one of the important step in Tympanoplasty, which is made to remove bony overhangs. There are multiple advantages with canalplasty. First of all canalplasty makes post-operative examination of the TM easy and also facilitates aural toilet and therefore prevents otomycosis or secondary infection. The raw bone surfaces after the canalplasty helps graft uptake. The wide canal also improves hearing. It is ideal to make canalplasty in all routine myringoplasty and tympanoplasty surgeries.
Page 42: Secrets of success in Tympanomastoid surgeries

4242

CanalplastyCanalplasty

Position of bony overhang :Position of bony overhang :

Other2%

Postero-Superior

4%

Postero-inferior65%

Anterior29%

Page 43: Secrets of success in Tympanomastoid surgeries

4343

CanalplastyCanalplasty

One should be able to see complete One should be able to see complete annulus at one microscope position. annulus at one microscope position.

Dr.Prahalad
The objective of canal plasty is to make the outer diameter of bony external auditory canal twice that of bony annulus. After the canalplasty one should be able to view the complete bony annulus at one microscopic position.
Page 44: Secrets of success in Tympanomastoid surgeries

4444

Step 7 :Step 7 : Cortical MastoidectomyCortical Mastoidectomy

Understand the controversyUnderstand the controversy Listen to the argumentsListen to the arguments Do what your heart saysDo what your heart says

Dr.Prahalad
Step 7: is Cortical Mastoidectomy. There is lot of controversy regarding cortical mastoidectomy during tymponoplasty. Undertstand the controversy. There are equal number reports advocating for as well as against cortical mastoidectomy during routine tympanoplasty and myringoplasty surgeries. I would advice junior colleaugues to just listen to the arguments and do what your heart says. As a junior surgein it is better to do cortical mastoidectomy in all cases.
Page 45: Secrets of success in Tympanomastoid surgeries

4545

Guiding principleGuiding principle

X-Ray Mastoid.X-Ray Mastoid.

Sclerotic83%

Pneumatized

17%

Dr.Prahalad
Indications for Cortical Mastoidectomy during routine tympanoplasty surgeries are controversial. One guiding principle I use is through X-Rays Mastoids. I get done X-Rays mastoid in all cases. If mastoid is pneumatized on X-ray, it indicates patent aditus and attic. I avoid cortical mastoidectomy in these cases. In cases where Mastoid is sclerotic, it indicates blocked aditus and attic, and therefore requires cortical mastoidectomy. In our experience 83% of the cases with Chronic Otitis Media were found to have sclerotic mastoids on the X-ray mastoids.
Page 46: Secrets of success in Tympanomastoid surgeries

4646

Technique of Cortical Technique of Cortical MastoidectomyMastoidectomy

Canalplasty Canalplasty firstfirst Mark cortical mastoidectomy land Mark cortical mastoidectomy land

mark initiallymark initially Antrum lies postero-superior to Antrum lies postero-superior to

Spine of Henle, Spine of Henle, not posteriornot posterior Do Cortical Do Cortical mastoidectomy/Not mastoidectomy/Not

just antrotomyjust antrotomy Don’t burr hole !?Don’t burr hole !?

Dr.Prahalad
Few tips regarding cortical mastoidectomy. Do canalplasty before doing cortical mastoidectomy. Make markings for cortical mastoidectomy before making canalplasty using drill. Antrum lies postero-superior to Spine of Henle, not posterior to it. Therefore you should concentrate your drilling in the postero-superior region. Always do cortical mastoidectomy not just antrotomy. Blind antrotomy is dangerous. Never make Burr hole ??? (Antrotomy).
Page 47: Secrets of success in Tympanomastoid surgeries

4747

Consider alternativeConsider alternative

Limited atticotomy and attic Limited atticotomy and attic reconstruction. reconstruction.

VideoVideo

Dr.Prahalad
If not cortical mastoidectomy, you can also consider limited atticotomy with attic reconstruction. It is at tympanic diapragm and tympanic isthmus, the obstruction present for routes for ventilation.
Page 48: Secrets of success in Tympanomastoid surgeries

4848

Step 8 :Step 8 : OssiculoplastyOssiculoplasty

Check for mobility/round window Check for mobility/round window reflex.reflex.

Gentle is the word.Gentle is the word. Excise tympanoslerotic plaquesExcise tympanoslerotic plaques Reconstruction with Autologous Reconstruction with Autologous

Incus/Conchal cartilageIncus/Conchal cartilage

Dr.Prahalad
Try to do Ossiculoplasty whenever necessary. Don't give up. You can do ossicular reconstruction using autologous incus or conchal cartilage. Before doing an Ossiculoplasty check the mobility of stapes and presence of round window reflex. But be gentle. Rocking movements of ossicles can result in permanent SN loss. If there are any tympanosclerotic plaques, please excise them.
Page 49: Secrets of success in Tympanomastoid surgeries

4949

Step 8 : Step 8 : Grafting techniqueGrafting technique

UnderlayUnderlay InterlayInterlay Excise the remnants of TM and Excise the remnants of TM and

Fibours annulus completelyFibours annulus completely– Total/Subtotal perforationsTotal/Subtotal perforations– Epithelium has grown insideEpithelium has grown inside– Mucosa has grown outsideMucosa has grown outside

Dr.Prahalad
Ideal Method of grafting is Underlay method. Graft uptake rate and hearing improvement are better with Undelay method. Alternative you can also do interlay method. In interlay method the remnants of tympanic memrbane is excised along with the fibrous annulus. This technique is particularly useful in total/subtotal perforations, and in perforations where the mucous memrabne has outgrown or epithelium has grown inside along the margins of the perforation.
Page 50: Secrets of success in Tympanomastoid surgeries

5050

Step 8 : Step 8 : Grafting techniqueGrafting technique

Medial / Lateral to malleus ? Medial / Lateral to malleus ? Medial to malleus :Medial to malleus :

– Foreshortened malleusForeshortened malleus– Malleus adherent to promontaryMalleus adherent to promontary

Lateral to malleus : Lateral to malleus : – All other situations.All other situations.

Dr.Prahalad
Next quesiton which arises, whether to medialize the graft medial to malleus or not. If possible medialize the graft medial to malleus in all cases. What I do is, I medialize the graft medial to malleus in cases where the malleus is foreshortened or retracted medially or in cases where malleus is adherent tot he promontary. In all other cases I leave the graft lateral to the malleus.
Page 51: Secrets of success in Tympanomastoid surgeries

5151

Step 8 : Step 8 : Grafting techniqueGrafting technique

Technique of Medializing the graft Technique of Medializing the graft medial to the malleus. medial to the malleus.

Page 52: Secrets of success in Tympanomastoid surgeries

5252

Malleus : Foreshortened/Malleus : Foreshortened/Adherent to promontoryAdherent to promontory

Never cut tip of the malleus.Never cut tip of the malleus. Epithelium is never adherent to Epithelium is never adherent to

malleusmalleus /only fibrous layer can. /only fibrous layer can. Length of the malleusLength of the malleus is important is important Cut the tensor tympani tendon to Cut the tensor tympani tendon to

increase the middle ear spaceincrease the middle ear space

Dr.Prahalad
What to do when the malleus is foreshortened or retracted medially or adherent to the promontary. You can release the adhesion and free the malleus. You can also cut the tensor tympani tendon to release the malleus. But never cut tip of the malleus. The length of the malleus is important for hearing results. Sometimes one gets tempted to cut the tip of the malleus whenever some soft tissue is attached to it, for the fear of retaining some epithelium there. There is nothing to worry about. Such soft tissue is always the fibres of middle layer of tympanic membrane.
Page 53: Secrets of success in Tympanomastoid surgeries

5353

Step 9 :Step 9 : Stabilizing the graft and flapsStabilizing the graft and flaps

Prevent anterior blunting. Prevent anterior blunting. Pack Middle ear and External Pack Middle ear and External

auditory canal properly. auditory canal properly. Prevent haematoma beneath Prevent haematoma beneath

Tympanomeatal/Koerner’s flaps. Tympanomeatal/Koerner’s flaps. Prevent narrowing of EAC. Prevent narrowing of EAC.

Dr.Prahalad
The graft needs to be stabilized properly with gelfoam pieces in middle ear and external auditory canal. Extra care is given at anterior part to prevent anterior blunting. Prevent collection of blood and haematoma formation beneath the Koerner's flap and tympanomeatal flaps to prevent narrowing of the external auditory canal.
Page 54: Secrets of success in Tympanomastoid surgeries

5454

Step 10 :Step 10 : Post-op CarePost-op Care

Record the mistakesRecord the mistakes Analyze your resultsAnalyze your results Improve on themImprove on them Failures – Do free revisions !Failures – Do free revisions !

Dr.Prahalad
Do not worry about mistakes. All mistakes you do today, have already been done by some one else, even best surgeons, earlier. But we have to learn from our mistakes and move on. Whatever mistakes you do, write them down in a separate personal dairy. Follow -up the patients regularly for at least 6 months. Analyze the results against the background of your mistakes. Such analysis will establish the cause and effect relationship between your mistakes and the results as well as post-op complications and problems. This is very important to realize the intricacies of various surgical steps. Improve your surgical techniques and rectify your mistakes. Remember the word “Kaizen” again. Make sure that there is daily progressive improvement.Nobody can be 100% perfect. While on the road, you are likely to have failures. Don’t get depressed. Remember, failure is not a person, failure is an event only. Failures are first stepping stones for success. With very failure you should become more determined to succeed. When you fail, don’t avoid the patient or refer them elsewhere and wash off your hands. Try to convince the patient and do revision surgery. If patient cannot afford a revision, do them free or at your own cost. This will earn you more patients. Remember, good experience does not come free. It has a price tag on it.
Page 55: Secrets of success in Tympanomastoid surgeries

5555

Every success story is also a story of great Every success story is also a story of great failurefailure

““Failure is the Highway to Failure is the Highway to Success”Success”

Dr.Prahalad
“Every success story is also story of great failure”. Read the story of Abrahom Lincoln or Thomas Alvas Edison. Realize, “Failure is the highway to success”.
Page 56: Secrets of success in Tympanomastoid surgeries

5656

““If you want to succeed, double your failure rate”If you want to succeed, double your failure rate”

Tom Watson Sr., of IBMTom Watson Sr., of IBM

Dr.Prahalad
I would like to say few more words about failure. The founder of IBM Computers, Tom Watson Sr., II says, “If you want to succeed, double your failure rate”. Failure is part of parcel of our quest for success.
Page 57: Secrets of success in Tympanomastoid surgeries

5757

Life is full of CompromisesLife is full of Compromises

Life is full of happiness & sorrowLife is full of happiness & sorrowGood and BadGood and BadDark Spots and Bright spotsDark Spots and Bright spots

Dr.Prahalad
Understand, “Life is full of compromises”. See the rainbow in the background. It takes both sunshine and rain to make a rainbow. It applies to our life also, “Life is full of happiness and sorrow”, “Good and Bad”, and “Dark spots and Bright Spots”.
Page 58: Secrets of success in Tympanomastoid surgeries

5858

“Perseverance”

Dr.Prahalad
Amidst of all these only thing which can ultimately take you to the peak, i.e., success is your “Perseverance”. What ever may come, irrespective of initial failure, if you persevere, or never take off your eyes from the goal, or keep working hard, the rewards are definitely there. You will definitely reach your goal.
Page 59: Secrets of success in Tympanomastoid surgeries

5959

Manage you time!Manage you time!

Father of Scientific ManagementFather of Scientific Management Frederick Taylor (1856-1915)Frederick Taylor (1856-1915) TaylorismTaylorism

Page 60: Secrets of success in Tympanomastoid surgeries

6060

Our Vision for the Year Our Vision for the Year 2007-082007-08

To achieve $ 231 million in revenue.To achieve $ 231 million in revenue.

To be among the top 10% in our business in terms of To be among the top 10% in our business in terms of profit after tax (PAT) and return on investment (ROI).profit after tax (PAT) and return on investment (ROI).

To be one of the top 20 globally admired companies in To be one of the top 20 globally admired companies in our industry.our industry.

To give a significant portion of our PAT to support To give a significant portion of our PAT to support primary education.primary education.

Dr.Prahalad
See this slide. Mindtree consulting is budding but reputed software company based in Bangalore. See their goals or “Our vision for the Year 2007-08”. Then ready what they want to achieve by 2007-08. To achieve $ 231 million in revenue. To be among the top 10% in our business in terms of profit after tax (PAT) and return on investment (ROI). To be one of the top 20 globally admired companies in our industry. To give a significant portion of our Profit after Tax payment (PAT), to support primary education.This shows power of goal making. Not having goals or not being focused is like getting into a bus/train without asking where it is going. It is a like boat without the navigator. One should be clear about what they want to achieve. Write them down and stick them some place, which you can see every day. Read them out loudly everyday, morning and evening, and work hard to make them come true. While first three points of goals of Mindtree consulting, speak of their Financial Goals, the last point speaks of their commitment to society. They call Corporate Social Responsibility. We all have social responsibilities. We have to help the people from who we make an earning and learning. Do help poor and needy. Do free camps and free surgeries for the poor patients. Still you are the one who will be benefited maximum. Experience does not come cheap!Remember, “A patient can survive without a doctor, but the a doctor cannot survive without patient”.
Page 61: Secrets of success in Tympanomastoid surgeries

6161

Page 62: Secrets of success in Tympanomastoid surgeries

6262

Page 63: Secrets of success in Tympanomastoid surgeries

6363

Page 64: Secrets of success in Tympanomastoid surgeries

6464

CCaring

LLearning

AAchieving

SSharing

SSocial

Responsibility

Dr.Prahalad
Be a CLASS your own. CLASS stands for:C - Caring. Always care for your patients and their feelings. Be passionate about your work and be compassionate about your patients. L – Learning. Learning is a never ending process. Remember “Kaizen”, the daily progressive improvement. A – Achieving. Make goals and work hard to achieve them. Reward yourself whenever you achieve something or reach a goal. S – Sharing. Share your success with your family, friends and foes! Teach others what you learned. Never keep the knowledge for yourself. Knowledge is to be shared, not hidden. If you share, every one will praise you when you are gone, if you keep it with yourself, it will be buried or burnt along with you. Today we able practice one of the highest qualities of surgery and medicine because someone shared, published, taught and demonstrated. S – Social Responsibility. Remember you always owe a lot to the society from whom you are making a living. Give something to the society from which you have learned and earned.
Page 65: Secrets of success in Tympanomastoid surgeries

6565

Thank youThank youwww.kenthospitals.com