Temporal Bone Dissection - The ZURICH Guidelines

L ON
ION
In collaboralion wilh
Deparlment ot ENT, Lucerne Cantonal Hospital, Switzerland
TEMPORAL BONE DISSECTION
- The ZURICH Guidelines -
Prof. Ugo FISCH, M.D.
ENT Center, Hirslanden Hospital, Zurich, Switzerland
In collaboration with
Assoc. Prof. Thomas LINDER, M.D.
Department of ENT, Lucerne Cantonal Hospital , Switzerland
89 Illustrations by
Katja Dalkowski, M.D.
Buckenhof, Germany
This booklet is based on teaching material distributed at
the yearly held Temporal Bone Dissection Courses organized
by the Fisch International Microsurgery Foundation
at the Anatomy Department of the University of Zurich, Switzerland
Chairman: Prof. Peter Groscurth, M.D.
We are grateful to the following persons,
who have helped in our courses for more than
15 years and contributed in developing the principles
exposed in this booklet:
Prof. John May, M.D.
Wake Forest University, Winston Salem NC, USA
Prof. Rodrigo Posada, M.D.
University of Pereira
Pereira, Colombia
FISCH INTERNATIONAL MICROSURGERY FOUNDATION

4
Illustrations by:
Katja Dalkowski, M.D.
Grasweg 42
0-91054 Buckenhof, Germany
Email: kdalkowski@online.de
Please note:
Medical knowledge IS aver changmg. As new research
and clinical broaden our knowledge, changes
in treatment and drvg therapy may be reqUIred. The
and editors of the material herein have consulted
sources believed to be reliable in their efforts to proVide
information thaI IS complete and in accordance With the
standards accepted at the time of publication. However.
in view of the poSSibility of human error by the authors,
editorS. or publlshef 01 the work here,n. or changes In
medICal knowledge. n&lther the authors. editors. publish-
er, nor any other party who has been inVolved in the
preparation 01 thIS work, warrants that the infOfmahon
contained herem is 10 every respect accurate or complete.
and they are not responSible for any errors or orlllSSIOflS or
lor the results obtained from use 01 such InlO4TT1atlon. The
onformatoon conlall1ed wlthtn thiS brochure IS Intended fOf
use by doctOfS and other heallh care professoonals This
matenal IS nol Inleoded fOf use as a baSIS for treatment
OeclSoonS. and IS not a substitute fOf professional consul
tatlOO and/Of peer-reviewed medICal hletature.
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deslgns referred to 111 thiS booIIlet are In facl registered
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erence 10 thiS fact IS nol always made In lhe text
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as propnetary IS not to be construed as a representation
by the publisher that It is in the public domain.
Temporal Bone Dissection - The Zurich Guidelines
Temporal Bone Dissect ion - The Zurich Guidelines
Prof. Ugo FISCH, M.D.
ENT Center, Hirslanden Hospital, Zurich. Switzerland
In col laboration with
Assoc. Prof . Thomas LINDER, M.D.
Department of ENT, Lucerne Cantonal Hospital. Switzerland
Contact:
Fisch International Microsurgery Foundat ion
Forchstr. 26. CH-8703 Erlenbach
Switzerland
Phone: +41 (0) 1 9106828
Fax: +41 (0)1 9106126
Email: fisch@orl-zentrum.com
C 20Cl6 Endo-Press"'. Tutthngen, Geliliany
ISBN 3-89756-106-9. Pnnted In Gem1any
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Typesetting and Image Processing:
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Printed by:
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Temp
Tal

Temporal Bone Dissection - The Zurich Guidelines 5
Table of Contents
A.1 Introduction .................. .. . . ........... .. . . . . .... . .. . ... ........ 6
A.2 General Preparation ............. . . . . . ... .. . . . .. ... . .... . . . ....... . .... 6
A.3 Specific Surgical Techniques ...... . .. . . . . .. . . . .. . . .. . . . ...... . . . . .. ... 7
B Closed-Cavity Technique .... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
B.1 Tympano-Antrotomy
(Meatoplasty, Canalplasty, Myringoplasty, Antrotomy,
Epitympanotomy, Osslculoplasty, Mastoid Drainage) .... . . .... ........ 7
B.1.1 Meatoplasty . . ..... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
B.1.2 Canalplasty ......................................... . . . . . . . . . . . . g
B 1.3 Myringoplasty ............ . . ...... ................ . . . .. . . .. ...... 13
B.1.4 Antrotomy ................. . . .... ................ . . .... ......... 15
B.1.5 Epitympanotomy .............. . . .. .................. . . .. ......... 15
B.1.6 Transmastoid Drainage of the Antrum ............................... 16
B.2 Tympano-Mast oidect omy
(Meatoplasty, Canalplasty, Epitympanectomy. Mastoidectomy,
Posterior Tympanotomy, Ossiculoplasty, Myringoplasty, Mastoid Drainage)
B.2.1 Mastoidectomy ............................................. 17
B.2.2 Posterior Tympanotomy ...... ................ ...... .......... 17
B.2.3 Epitympanectomy ........... ............ ...... ...... . . . . .. . . 18
B.3 Myringoplasty and Ossi culoplasty in Closed Cavities
B.3.1 Myringoplasty ......... . .......................... . . .. . .. .. 19
B.3.2 Ossiculoplasty (Incus-Interposition) .................. . .. ...... . 20
C Stapedotomy
C.l Incus-Stapedotomy .............................................. 22
C.2 Malleo-Stapedotomy ............ ... ................... ... ......... 28
o Open Cavity Techniques (Mastoido-Epitympanectomy, Open MET)
D.1 Mastoidectomy ........ ........ ........................ .... . .. ... 32
D.2 Epitympanotomy ................................................ . 34
0 .3 Completion of Mastoido-Epitympanectomy .......................... 34
E Tympanoplasty (Myringoplasty and Ossiculoplasty) in Open Cavities ......... 35
E.l Type III Tympanoplasty ....... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
E.2 Total Reconstruction of the Ossicular Chain .......................... 36
E.2. l Fisch Titanium Total Prosthesis .......................... . . . . . . . . . . . 36
E.2.2 Titanium Neo- Malleus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
F Additional Temporal Bone Di ssections
F.l Subtotal Petrosectomy .... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
F.l.1 Subtotal Petrosectomy with Preservation of the Otic Capsule ........ ... 42
F.l.2 Subtotal Petrosectomy with Removal of the Otic Capsule .... . . . . . . . . . . . 43
G Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
H Prostheses and Instruments
H.l FISCH Titanium Middle Ear Prostheses. . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
H.2 FISCH Special Instruments for Tympanoplasty,
Mastoidectomy and Stapedotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
-
6
A.1 Introduction
The series of surgical techniques described in this article
relates to procedures that can be practiced in a course
using two temporal bones. The first bone is used to
demonstrate the closed-cavity tympano-mastoidectomy
with related myringoplasty and ossiculoplasty (incus inter-
poSition). The second bone is used to demonstrate stapes
surgery and malleo-stapedotomy) and
open-cavity mastoido-epitympanectomy.
The surgical steps described in these guidelines require
special instrumentation. The most important instruments
are mentioned in the text, highlighted in italics. For more
details on Prostheses and Instrumentation see Section H.
More information concerning the described surgical proce-
dures is given in Section G (Suggested Reading),
ArtICular tube:le
CD Temporal line
<i) Spine of Henle
@ Tympar.ornastold suture
M. sternocleidomastoideus
A.2 General Preparation
The temporal bone should be placed in the normal operat -
ing position, with the posterior aspect toward the surgeon
and the temporomandibular joint away from the surgeon.
Remove excess bone from the temporal squama using a
cutting burr to ensure that the remaining temporal bone fits
within the holder, permitting complete rotation in the
anlero-posterior plane.
Initially, the external ear is left attached to the temporal
bone to enable the meatoplasty technique to be performed
within closed cavities. Following meatoplasty (or when the
pinna is not available), the external canal is transected
2 em lateral to t he bone-cartilaginous junction. All excess
soft tissue that is not used during the dissection is
removed from the bone.
Identify the following anatomical landmarks (Fig. 1):
CD Temporal line Tympanomastoid suture
<i) Spine of Henle Tympanosquarnous suture
@ Mastoid tiP Petrotympanic fissure
Zygomatic process
, I
Petrotympanic fissure
Styloid pmcess
TympaniC booe
Mastoid process
--@Mastold tip
M. dlgastncus
M. longus capi tis
1
M. spleniUS capitis

Tomp
A.3
Be
B.l
The!
Meat.
Antro
B.l .
GenE
Meat.
when

(Fig. ,
edto
sis ar
ment
exter
sel f-c
canal
The I
c"'"
b" A-

Skin
The t
positl
enda
to thl
tory (
The ,
throo
EAC
A thi
CISIOI
(Fig.
Elev,
Theb
SCISS!
culan
meot
A.3 Specific Surgical Techniques
B Closed-Cavity Technique
B.1 Tympano-Antrotomy
The steps of thi s operation are:
Meatoplasty, Canalplasty, Ossiculoplasty, Mynngoplasty,
Antratomy, Epitympanotomy and Mastoid Drainage,
B.1.1 Meatoplasty
General Considerations
Meatoplasty is a necessary step in addition to canalplasty
when the cartilaginous portion of the external auditory
canal (EAC) is too narrow in relation to its osseous portion
(Fig. 2 a, C), Lateral stenosIs of the EAC is commonly relat-
ed to congenital anomalies, minor malformations, exosto-
sis and postsurgical scarring. It may lead to hearing impair-
ment, excessive accumulation of cerumen, chronic otitis
externa, difficulties in clinical examination and insufficient
self-cleansing properties of the external ear following
canalplasty.
The principle of meatoplasty is to remove the obstruction
created by excessive conchal cartilage and bone (Figs. 2 a,
b; A-B). The operation is performed with a microscope,
Skin Incision
The first superior skin incision begins at the 12 o'clock
position between the tragus and helix, as is the case of an
endaural approach (Fi g, 3, A-B-C), and is cont inued down
to the level of the superior edge of t he bony external audi -
tory canal.
The second incision is made at 6 o'clock and cont inues
through the ring of cartilage forming the inferior edge of the
EAC (Fi g. 3, O-E).
A third, medial skin incision connects both previous in-
cisions horizontally along the posterior edge of the EAC
(Fi g. 3, C-D).
Elevation of the Laterally Based Skin Flap
The laterally based skin flap IS elevated using tympanoplasty
scissors. Care must be taken to keep the skin intact, parti-
2.
3
cularly when separating it from the thin but strong attach- A
ment to the conchal cartilage (Fig. 4).
4
. ,,' .
'-'II.
" ,
.' ,
."
,
c
Endaural Retractor
7
' E
8
Bony external canal
5.
B

7
8
Skin flap
F
Conchal
cartilage
E
Relieving
inciSion
E
Excess of bone behind
external auditOf)' canal
5.
Edge of excised
conchal cartilage
Exposure and Excision of Conchal Cartilage
Excess conchal cartilage is exposed (Fig. 5 a) and excised
(Fig. 5 b). and the soft tissues situated between the
excised cartilage and the underlying bone are also
removed.
Enlargement of the Bony EAC
The posterior wall of the bony EAC is enlarged using a dia-
mond burr (Fig. 6).
Wound Closure
Before closing the wound, a rel ieving Incision is made
through the inferior part of the laterally based meatal skin
flap (Fi g. 7, F) to allow superior rotation of its upper part
(Fi g. 8, C, 0). In this way, the enlarged superior external
auditory meatus is completely covered with skin. which is
kept in position with 4-0 Et hibond sutures (Fig. 9), The
inferior enlarged portion of the EAC is left open and will
heal by secondary intention within 2-3 weeks.
NOTE: A meatoplasty can be performed on the tempo-
ral bone only if the pinna has been preserved. Pertorming
a meatoplasty will not allow the surgeon to carry out the
first steps of the retroauricular approach described under
B 1.2.
9
,
6.1.
Gent
The
shou
exler
annu
Peril
The
with
size
is al
(Fig.
Exp<
The
"pe
the ,
open
(Fig.
tissu
lory.
Aetroauricular
'0
B.1.2 Canalplasty
The goal of any tympanomastoid surgical procedure
should be the circumferenttal enlargement of the bony
extemal canal to visualize the entire ring of the tympanic
annulus using one position of the microscope (Fig. 10).
Periosteal Flap
The outline of the relroauricular periosteal flap is formed
with a knife (No. 15 blade) and should be approximately the
size of the index finger (Fig. 11 , A). The periosteal flap
is elevated from the bone with a mastoid raspatory
(Fig. 11, B).
Exposure of the EAC
The posterior limb of the canal incision (Fig. 12, A-B)
is pertormed with a No. 15 blade, maintaining a level below
the entrance of the bony external canal. The EAC is then
opened and the canal incision is extended anteriorly
(Fig. 13, B-C) 10 the 2 o'clock position (right side). The soft
tissues are moved away from the bone using a Key raspa-
tory.
9
'"
11b
12
13
'0
'40
'50
Meatal Skin Flap
Visualization of the entire tympanic membrane using one
position of the microscope is made possible by forming a
large meatal skin flap that is carefully dissected out of the
canal with its inferiorly based pedicle left in place. In the
clinical setting, the advantage of this type of flap is that its
blood supply is maintained through its pedicle.
Incisions for the Meatal Skin Fl ap
The meatal flap is incised using a No. 11 blade mounted in
a special rounded scalpel handle. The blade is guided
along the lines shown in Figs. 14 a (right ear) and 14 b (left
ear).
Two Incisions are made: the first spirally ascending from
medial to lateral (Figs. 14a, b; D-C), and the second run-
ning medially and circumferentially (D-E).
The spiral incision starts 2 mm tateral to the annulus at
7 o'clock (right temporal bone) and swings up laterally
along the anterior canal wall to meet the previously cut
external canal skin at 2 o'dock (C). Be aware that skin inci-
sions in the temporal bone do not bleed and are at times
difficult to visualize. Therefore, it is highly advisable to keep
in mind the track previously used by the tip of the knife and
to make the incision in a step-by-step fashion. The corre-
sponding skin incisions for the left ear are shown in Fig. 14 b.
Temporal Bone Dissecf on - The Zurich Guidelines
A
15"
'5c
Elevation of the Meatal Skin Flap
I
7em
"

The skin is elevated from the bone using a Fisch microras-
patory in the right hand and a microsuction tube in the left
hand (Figs. 15 a, b). The microsuction tube should have a
length of 7 em to permit the surgeon's left hand to rest
comfortably on the head of the patient (Fi g. 15 b).
The tiP of the microsuction tube holds the skin away. The
amount of negative pressure of the microsuction tube is
controlled with the left index finger (Fig. 15 b).
The tip of the microraspatory should always remain in con-
tact with bone. Small movements separate the meatal skin
from the bony EAC in the vertical and horizontal planes
(Fig. 15 c). A small strip of gauze soaked in saline solution
protects the skin during separat ion from t he bone with the
Fisch microraspatory.
\
Tem]:!
eire
Folic
flap,
ed, ,
the t
Oeft ,
Fi gs
USln!
sors
of th
cutti
flap
knife
50",
limb
Fig.
Fig.
Ete"
CarE
ic be.
sian
mas
'he
(Fig.
'"
16c
,
,
.. ----'.
Circumferential Skin Incision
D
Following elevation of the lateral part of t he meatal skin
flap, the circumferential incision of the meatal skin is creat -
ed, beginning and ending (Fig. 16 a, D-E) 2 mm lateral to
the tympanic annulus at 7 o'clock (right ear) or at 5 o'clock
(left ear), at the starting point of the spiral incision (see also
Figs. 14 a, b). The anterior limb of the incision is carried out
using tympanoplasty microscissolS (modified Bellucci scis-
sors) along the edge of the antero-inferior bony overhang
of the EAG. The posterior limb of the incision is initiated by
cutting through the posterior surface of the meatal skin
flap with a No. 11 blade mounted to a rounded scalpel
knife (Fig. 16 b). The incision is then continued along the
superior canal wall connecting the anterior and posterior
limb with straight mlcrotympanoplasty scissolS (Fig. 16 c).
Fig. 16 d shows the completed meatal skin flap (see also
Fig. 14 a).
Elevation of Meatal Skin Flap from the Tympanic Bone
Gare is taken at this stage to expose the complete tympan-
ic bone, including its lateral sur1ace. This requires an exten-
sion of the base of the meatal skin flap from the tympano-
mastoid sut ure in t he antero-superior direction to include
the posterior and lateral sur1ace of the tympanic bone
(Fig. 17, C-D).
16b

16d
~ _ c
Medial
skin
ofEAC
17
c
Skin covering
lateral portion
of tympanic bone
DE
D
1 1
A
Meatal
skm nap
12
18
20a
20b
roc
"
\

,
,
,
,
Key raspatory
TymparlO- Exposed lateral
squamous surface 01
suture tympaniC bone
Medial
skm of
EAC
I
Tympano-
mastoid suture
19
.--
.--
--
--
.. ,
Meatal
ff-
skin
flap
-_ .. ,/
... '
Separation of the skin covering the posterior surface of the
tympanic bone is accomplished uSing a Key raspatory. The
tip of the raspatory is moved along the lateral portion of the
anterior bony canal wall, and then gently rotated anteriorly
to completely uncover the superior edge of the tympanic
bone (Fig. 18). In this way. the lateral surface of the
tympanic bone Is completely exposed from the tympano-
mastoid to the tympana-squamous suture. This exposure
is a prerequisite to performing an adequate circumferential
canalplasty (Fig. 19).
Canalpl asty
Most commonly. viewing is limited to the antero-inferior
portion of the drum owing to an excess of tympanic bone.
The correct enlargement of the EAC is obtained by drilling
away the overhanging bone with sharp and diamond burrs
(Fi gs. 20 a-c).
In a narrow EAC, It is difficult to identify the antero-inferior
tympanic annulus, which may be completely covered by
bone. In this situation, a groove (trough) is made in the
bony infenor canal wall at 6 o'clock (Fig. 21) until the white
hne of the tympanic annulus becomes clearly visible. This
techmque of the mfenor trough was developed to avoid
injuring the facial nerve, jugular bulb or internal carotid
artery because these structures are out of reach if the
drilling is performed along the inferior EAC wall and
remains lateral to the tympaniC annulus (Fig. 21).
After identification, the tympanic annulus is progressively
exposed as far as the anterior and posterior tympanic
spine. When all bone overhangs are eliminated, the com-
plete drum can be viewed without having to readjust the
position of the microscope (Fig. 22 a and b).
After correct canalplasty. it may become necessary to
apply relieving incisions on the medial meatal skin to return
it to a proper position (Fig. 22 b).
,

Tempe;
Tympa
annull
"
B.1.3
Midd
for G
Fresh
Then
usmg,
This
provid
Eleva!
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With II
terior t
handlE
and tt
tympa
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annuh.
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Elevat
conlin
the
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terms
retatlOi
not in
""'ne
page
the rig
betw.
and 11
left SJ.
annull
the fur
Divisi(
(Swint
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Tympanic
annulus
TympanIC
annulus
21
,
8.1.3 Myringoplasty

Middle Ear Inspection and Preparation
for Grafting
Freshening the Perforation Margins
The margin of the large central perforation is refreshed
using ultrafine biopsy forceps (Fig. 23 a) .
This is done before elevation of the tympana meatal flap to
provide sufficient stability of the drum,
Elevation of the Tympanomeatal Flap
A posterosuperior tympanomeatal flap is elevated
with the microraspatory starting from the pos-
terior tympanic spine to expose the malleus
handle. the long process of the incus.
and the stapes (Fig. 23 b). The chorda /""""
tympani is preserved and separated
from the undersurface of the drum
using a Fisch Ten%m. The inferior
annulus is separated from his bony
sulcus using a microdissector (Fig. 23 c).
Elevation of the tympanomeatal flap IS
continued to the 4 o'clock position (on
the right side versus 8 o'clock in a left
bone) to gain sufficient anterior access for
fixallOn of the underlay graft. Note that the
terms Munder_ and are used In
relation to the bony tympanic sulcus and
not in reference to the tympanic mem-
brane (see also 8.3.1. Myringoplasty,
page , 9) Never elevate the annulus of
the right anten'or tympana-meatal angle
between 2 and 4 o'clock (or between 8
and 10 o'clock. respectively. on the
left Side). Elevation of the anterior
annulus leads to blunting and impairs
the functional results of tympanoplasty.
Divi si on of the Tympanomeatal Flap
(Swinging-Door Technique)
The elevated tympanomeatal flap is divided
posteriorly using tympanoplasty microscissors
to form two swinging-door flaps (Fig 23 d).
230
23c
22.
22"

_I
13
230
23d
14
,
2 ..
An,_
matleal ligament
Anterior
tympaniC
spine
24b
240
Posterior
tympanic
spine
Anterior
mallea! process
Inspection of the Ossicular Chain
Enlarge the postero-superior canal wall with a small curette
10 expose the anterior malleal process and ligament, the
InclJdo-malieal toint, and the complete stapes (Figs. 24 a, b).
Check the integrity of the ossicular chain and verify its
mObility. Disarticulate the incudo-stapediaJ joint using a
Joint knife (Fig. 24 b) to prevent cochlear damage while
manipulating the ossicles (particularly the malleus handle).
Epithelial debris is cleaned from the malleus tip using a
1.5 mm 45
0
hook while the malleus handle is lateralized
with a second hook (Fig. 24c),
Adjunctive Anterior Fixation of the Underlay Graft
(Subtotal Perforation)
In the presence 01 subtotal or anterior perforations, the
tympanic annulus is separated from the sulcus between 1
and 2 o'clock (right ear) (Fig. 25 a). The antero-superior
portion of the temporalis fascia will be kept in position
t hrough t his gap. This eliminates the need to introduce
Gelfoam 1M into the protympanum to fix the fascia against
the lateral wall of the latter.
Drilling of the New Tympanic Sulcus
A new tympaniC sulcus is drilled with a small diamond burr
along the medial bony edge of the EAC between 4 and
2 o'clock (Fig. 25 b). This ledge of bone is used for later
positioning of the fascia as seen in the insert of Fig. 25 b.
",
--
.....

I
,
,
,
,
,
,
,
,
,
..
,
'.
,
\
,
,
,
,
,
,
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'.
25b ~ . ~ , . " '.': : ...

Tem
Fixatil
In su
under!
points
B.l.4
The.
eusta(
mucO!
mined
paraliE
The.
identlf
ble thr
The.,
tonize.
be ,en
0","",
(Fig. 2
B.l.5
Water
IrrigatE
bulb a
the ml
case,
cranial
28
Fixation Points for Underlay Grafting
In subtotal and large antero-inferior perforations, the
underlay fascial graft will be supported by the following
points:
CD On the ledge of the new antero-inferior tympanic SUl-
cus.
<V Under t he malleus handle.
CD On the posterior tympanic sulcus and chorda tympani.
@ On the gap between the antero-superior tympanic
annulus and sulcus.
B, 1.4 Antrotomy
The antrotomy is carried out when the function of the
eustachian tube is questionable or when the middle ear
mucosa is abnormal. The poSition of the antrum is deter-
mined by the intersection of the temporal line and a line
parallel to the posterior canal wall (Fig. 27).
The middle cranial fossa dura and the sigmoid sinus are
identified by drilling away the bone until they become visi-
ble through the last shell of covering bone (skeletonizarion) .
The antrum is found by removing the bone along the skele-
tonized middle cranial fossa dura. No bone should
be removed over the entrance of the EAC. The antrum is
opened until the lateral semicircular canal is exposed
(Fig. 28).
B.1.5 Epitympanotomy
Water Test for Epitympani c Patency
Irrigate the antrum with water dispensed from a rubber
bulb and ensure that the Ringer's solution flows freely into
the middle ear and out of the ear canal. If this is not the
case, drill away the bone along the skeletonized middle
cranial fossa in an anterior direction until the incus and
28

/
,
,
,
27
,
"
,
,
,
,
,
,
,
,
,
"
15
malleus head have been identified and exposed (epitympa-
notomy). Obstructing scars or thickened mucosa sur-
rounding the ossicles are removed to achieve adequate
patency of the aditus ad antrum (epitympanecromy) (see
Fig. 64, page 32).
29
16
300
30c
,
,
Retroauncular
skin incision
Stab incision
for drain
30b
Transmastold drain
8.1.6 Transmastoi d Drainage
of the Antrum
After exposmg the antrum, a groove is drilled posteriorty
along the sinodural angle to guide the transmastoid drain
(Kala-Drain) (Fig. 30 a). The polyethylene drainage tube,
having an outer diameter of 5 mm, has been bent by plac-
ing it over a curved metal stylus and healing it in an oven at
a temperature of BOoe. The angle of the bent lube is 110.
The Iransmastoid drain is placed with its bend in the
antrum through a separate relroauricular slab incision
using a curved clamp. (Figs. 30b, c).
B,2 Tympana-Mastoidectomy
General Consi derations
The sleps required for a closed
tamy with Tympanoplasty (MEl) are:
Meatoplasty, Ganalplasty. Epltympanectomy, Mastoidec-
tomy, Posterior Tympanotomy. Osslculoplasty, Myringo-
plasty, and Mastoid Dramage.
Some of these surgical steps are the same as for retroau-
ricular tympana-antrotomy and have been discussed in the
preceeding chapter (see page 7).
\
Tem,
B,2,
Iden
E
,
,
,

\
\
\
,
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"
,
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I
I
,
,
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I
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,
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the f
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pyra
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aM
ope,
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the t
pani
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B.2. 1 Mast oi dectomy
Identification of the Facial Nerve (Fig. 31)
Enlarge the ant rotomy superiorly by skeletonizing the
middle fossa dura. Perform t he epltympanotomy to
expose the incus and malleus head. Identify the tym-
panic segment of the facial nerve inferior to the later-
al semicircular canal <D.
Skeletonize the sigmoid sinus and expose the sin'
odural angle. Do not work in a hole or underneat h
bony edges!
Expose t he lateral surface of the digastric muscle
along the mastoid tip. Follow the superior edge and
lateral surface of the digaster muscle anteriorly to
identify the stylomastoid periosteal fibers (curving
antero-superior). and skeletonize the stylomastoid
foramen $.
Expose t he posterior semici rcular canal. Remember
that the pyramidal segment of the facial nerve is Situ-
ated 2 mm antero-Iateral to the inferior edge of the
posterior semicircular canal <D.
Use the lateral and posterior semicircular canals and
t he stylomastoid foramen to estimate the course of
the facial nerve. Skeletonize the mastoid segment of
the facial nerve in a retrograde fashion using large
diamond burrs to drill over a wide field on the com-
pact bone covering t he lateral surlace of the nerve.
B.2.2 Post eri or Tympanot omy
The space between the pyramidal segment of the facial
nerve, the chorda tympani, the buttress over the lateral
process of the incus, and the posterior canal wall is called
the facial recess (Fig. 32). There is great variability in size
and pneumatization of this area. The bone between the
pyramidal segment and the chorda tympani is drilled away
(Fig. 33) while keeping an eye on the skeletonized mastoid
and pyramidal segments of the facial nerve. The resulting
opening to t he middle ear is the posterior tympanotomy.
Avoid exposing the facial nerve (leave a small shelf of bone
to cover and protect the nerve) or touching the Incus With
the burr. and do not injure the chorda tympani and the tym
panic annulus. Do not make the posterior canal wall too
thin to avoid delayed atrophy (Fig. 33).
17
'"
32
33
18
34
, Sa
35b

1.5 mm
45' Hook
With the facial nef'Ve in view, the facial recess can be
enlarged as much as possible. If the mastoid is narrow, the
bony buttress behind the posterior ligament of the incus is
removed to gain sufficient space. A diamond burr is used to
lower the bone covenng the lateral semicircular canal, and
the pyramidal and distal tympanic segments of the fallopian
canal. This will also expose the chorda tympani (Fig. 34),
Through the posterior tympanotomy and epitympanotomy
the following middle ear structures should be identifiable:

stapes and stapedial tendon

tympanic segment of the facial nerve

round window

incus with short and long process

mal leus head, cochleariform process and tensor
tympani tendon

eustachian tube orifice (occasionally, Fig. 45)
8 .2.3 Epitympanectomy
The incudo-stapeclial joint is separated, and the incus is
mobilized with a 1.5 mm. 45hook (Fi g. 35a) then removed
by lateral rotation, preserving the chorda tympani
(Fig. 35 b). The long process of the incus may be cut with a
malleus nipper when the integrity of the chorda is at risk.
The chorda is separated from the undersurtace of the
malleus, and the malleus neck is cut with a malleus nipper
(Fig. 35 e) or, if the anterior malleal ligament is hyalinized,
with a 0.8 mm diamond burr (c.f. Fig. 58 e). The malleus
head and the chorda tensor fold are removed to ensure
free communication between protympanum and supratu-
bal recess.
Malleus nlpP6l'
I
,
Temp<>
~
B.3
B.3.1
Genet;
The tel
bony t,
the ty
means
used f(
contae
case, t
tympar
fascia.
over tt
tioned,
"orne,
Under1
For tra
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,ce,,",
(Fig. 3f
The 51
(excepl
cient 51
of the
handle
tympar
For sui
should
tympar,
at the 1
B.3 Myringo- and Ossiculoplasty
In Closed Cavities
8.3.1 Myringoplasty
The terms underlay and overlay are used in relation to t he
bony tympanic sulcus and not. as is usual . in reference to
the tympanic membrane, Therefore. anterior underlay
means that the temporalis fascia (or the piece of wet paper
used for it) is placed under the anterior tympanic sulcus in
contact with the lateral wal l of the protympanum. In this
case, Ihe tympanic annulus and anterior remnant of t he
tympanic membrane remain over the anteriorly underlaid
fascia. Posterior overlay means that the fascia is situated
over the posterior bony tympanic sulcus. When reposi-
tioned, the tympanic membrane remnant (or tympa-
nomealal flap) will cover the posteriorly overlaid fascia.
Underlay Grafting
For training purposes, use a wet piece of paper from the
surgical glove packing. An inciSion IS made with a knife
according 10 the expecled position of the malleus handle
(Fig. 36 a).
The swinging-door Iympanomeatal flaps are elevated
(except antenorty between 2 and 4 o'clock) 10 create suffi-
cient space for inserting the graft under the anterior margin
of the perforation, The graft is placed under the malleus
handle and rests over the chorda and the pastero-inferior
tympanic sulcus (Fig. 36 b).
For subtotal or large anterosuperior perlorations, the graft
should also be fixed between the sulcus and annulus
tympanicus at the 1 0 'clock position for the right bone and
at the 11 o'clock position for the left ear.
36b
37
(j)
The graft is supported althe following points (Fig. 37):
<D On Ihe inferior tympanic sulcus.
@ Under the malleus handle.
<D On the posterior tympanic sulcus and the chorda
tympani.
@) In the gap created antero-superiorly between the
tympanic annulus and tympanic sulcus.
19
20
r ___
38
39.
39b
B.3.2 Ossiculoplasty
8 .3.2.1 Incus Interposition
8 .3.2.2 Autologous Incus
In the presence of intact stapes, malleus handle and ante-
rior half of the drum, the preferred type of reconstruction is
the interposition of the autologous incus.
Measuring the Length and Angle of the Implant
The correct length and angle of the implant is measured
using a Fisch microraspatory that is 2.5 mm in length.
Shaping the Autologous Incus
The incus body is held firmly using a small curved clamp
while drilling with a diamond burr (Fig. 39a). The long
process and the posterior part of the incus body are short-
ened. Keep in mind that the plane used to shorten the incus
body determines the angle of the interposed ossicle. The
articular surface of the incus is carved, taking into consid-
eration the inclination of the malleus handle (Fig. 39 b).
A notch for the stapes head is drilled on the opposite side
using 0.6 and 0.8 mm diamond burrs (Fig. 3ge).

Tempo
Interp!
The m
handle
aod a
runs (
{Figs .
B.3.2.
A Tita
Genna
able {F
depen
micror
nectln!
rough.
a diam
be hel.
The tit
introdL
uSing
this pu
Iy as a
'"
40.
Interposition of the Modified Autologous Incus
The modified incus is rotated in contact with the malleus
handle over the stapes head using the largest microsuction
and a 1.5 mm, 45hook (Figs. 40 a, b). The chorda tympani
runs cranial to and stabilizes the interposed incus
(Figs. 40 a-c).
B.3.2.3 Titanium Incus
A Titanium Incus Prosthesis (KARL STORZ, Tuttlingen,
Germany) is used when the autologous incus is not avail-
able (Fig. 41 a). Prosthesis length selection (3, 4 or 5 mm)
depends on the measurement obtained with the Fisch
microraspatory (see Fig. 38). The prosthesis surlace con-
necting with the stapes head and malleus handle should be
rough. This is achieved by dri lling the contact surfaces with
a diamond burr. For this purpose, t he titanium incus should
be held wit h special incus-holding forceps (Figs. 41 b, c).
The t itanium incus is transported into t he middle ear and
introduced between the malleus handle and stapes head
using a 2.5 mm, 45hook inserted through holes made for
this purpose (Fig. 41d). The prosthesis is posit ioned exact-
ly as an interposed autologous ossicle (Fig. 41 e).
41b
j
C>
\---'-
'10
21
'Ob
41"
2.5 mm Hook
41.
22
42.
B
42b
,
"
Tympanoplasty
kmfe
, ............ _--- "':':
-r
f {T"""
/-A",/.1e.w
C Stapedotomy
Stapedotomy means the creation of a small calibrated
fenestration into the stapes footplate. The same name is
frequently used to indicate the introduction of a stapes
prosthesIs between the incus and vestibule, regardless of
whether the opening into the footplate is well calibrated or
consists of a partial removal of the footplate fenes-
tra stapedectomyj. From t he authors' point of view, the
definition of "stapedotomyN should be limited to the former
sit uation and the latter should be cal led a "partial
stapedectomy. N
The introduction of a stapes prosthesis from the malleus to
the vestibule has been called This term
does not address whether the prosthesis reaches the
vestibule through a calibrated opening, or through a partial
or total stapedectomy. To avoid this confusion, the authors
have introduced the terms incus-stapedotomy and mal/eo-
stapedotomy for the exclusive use of a stapes prosthesiS
from the Incus or malleus handle in conjunction with a
stapedotomy opening.
To achieve a stapedotomy opening through the footplate
on a regular basis, It has proven of value to reverse the
classic steps of stapedotomy and to create the calibrated
opening before removing the stapes arch. In this case, the
diameter of the stapedotomy opening should not exceed
0.5 mm, and the corresponding diameter of the stapes pis-
ton should be of 0.4 mm.
C.1 IncusStapedotomy
Endaural Skin Incision
The endaural skin incision (A-B in Fig. 42 a) is made using
a No. 15 blade at the 12 o'clock position between the tra-
gus cartilage and root of the helix. The soft tissues are cut
to the level of the bony entrance of the canal (remove
excess soft tissues over the bony external ear canal to gain
sufficient exposure in the temporal bone specimen).
Tympanomeatal Flap
The tympanomeatal incisions are made with a NO.l1 blade
mounted in a special rounded scalpel handle.
The posterior limb of the tympanomeatal flap begins at
8 o'clock, ascending spiraly from the tympanic annulus
to the lateral edge of the external auditory canal (C-A in
Fi g. 42 b). The anterior limb is carried out from the 1
o'clock position to the Inferior edge of the endaural incision
(D-A in Fig. 42 b).
NOTE: A larger tympanomeatal flap (as for malleo-stape-
dotomy, see page 28) is used whenever total or partial
fi xation of the malleus is suspected.
I
,
,
-<'"""\ " ,
Tarlipon
,/
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Rivinij ..
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to keep
Enlarge
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Teriolporal Bone DiSsection - The Zurich Guidelines
,
,
"',
Canalplasty
While elevating the tympanomeatal flap, the bony over-
hang of a prominent tympanosquamous spine or a pro-
truding antera-superior canal wall needs to be removed to
adequately inspect the anterior malleal process and
ligament (Figs. 43a-c). A curette or diamond burr is used
for this purpose (do nol separate the Iympanomeatal flap
from the tympanic sulcus and incisura Aivini during this
step to avoid irrigation of the middle ear with contaminated
Ringer's solution).
Elevation of Tympanomeatal Flap
The most important landmark in this step is the posterior
tympanic spine (posterior end of the incisura tympaniea
Aivini). The Iympanomeatal flap is elevated first from t he
posterior spine using a Fisch microraspatory. Care is taken
to keep the chorda attached to the flap (Fig. 44 a).
Enlargement of the Supero- Posterior Canal Wall
The bone covering the oval window, the inferior edge of t he
incudo-malleal joint and the anterior malleal process are
removed using a curette. The rotational movements of the
curette should be directed from medial to lateral to avoid
trauma to the chorda and incus (Fig. 44 b).
,
44,
43'
43<
44'
lateral
+

..

medial
23
24
45
.7
Anterior maJleal
ligament
Pyramidal ~ ;
process
> 1 mm _ .:.j
< lmm---
Stapedial tendon
6
Exposure of the Oval Window
The exposure of the oval window is correct when the fol-
lowing structures are visible (Fig_ 45):
Pyramidal process with the stapedial tendon
Oval window with the stapes and incudo-stapedial
joint
Tympanic segment of the facial nerve
Infenor incudo-malleal JOint
Lateral (short) process of the malleus
Anterior malleal process and ligament
Preparation of the Stapes Prosthesis
A malleable measun'ng rod is used to determine the dis-
lance between t he footplate and the lateral surface of the
incus (Fig. 46). This measurement should be increased by
0.5 mm to account for the protrusion of the prosthesis pis-
ton into the vestibule. The resulting total length of the pros-
thesis will average 5.2 mm. A 0.4 x 8.5 mm Titanium Stapes
Prosthesis (KARL STORZ. Tuttlingen. Germany) is trimmed
on a special Titanium Cutting Block (Fig. 47) and placed in
the preformed 0.4 mm hole for later use.
The stapes prosthesis is available in two other sizes: 0.4 x
10 mm and 0.4 x 7 mm. The longest prosthesis is used in
deep middle ears (part ially malformed ears), the shortest in
shallow middle ears (partially open cavities). The different

Ierlgths relate to the different distance between prosthesis ..
loop and 0.4 mm cylinder.
Perforation of the Footplate
A calibrated opening of 0.5 mm diameter is made in the
safe area (the central area between the middle and inferior
third of the stapes footplate) where the saccule and utricle
lie more than 1 mm below footplate level (Fig. 48 a). The
stapedotomy opening should be positioned in such a way
that the prosthesis will remain perpendicular to the foot-
plate.
,
...
A ..
diam
ope,
bet.
''''''
size
calip
Inlm
The:
uSln,
pisto
with
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If the
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alliga
.'"

Temporal Bone Oissection - The Zurich Guidelines
Manual perforators
0.3 0.4 0.5
48b
A set of four manual perforators (0.3, 0.4. 0.5 and 0.6 mm
diameters. Fig. 48b) is used to create the stapedotomy
opening. The periorators are rotated back and forth
between thumb and index finger. The tip of each periorator
is only partially introduced into the vestibule. The correct
size of the opening (0.5 mm) is confirmed with a 0.4 mm
caliper (Fig. 48 c).
Introduction and Fixation of the Stapes Prosthesis
The stapes prosthesis is picked up from the cutting block
using large straight smooth alligator forceps (Fig. 49 a). The
piston IS first placed over the stapes footplate and aligned
with the long process of the incus. The length of the pros-
thesis is correct if the piston loop exceeds the lateral sur-
face to the incus by 0.5 mm (Fig. 49 b).
II the prosthesis is the correct length, it is moved over the
stapedotomy opening with a 1.0 mm. 45 hook and care-
fully advanced into the vestibule (Fig. 49 b). The loop is
then crimped over the incus with small straight smooth
alligator forceps (Fig. 49 c).
49b
1.0 mm.
45' Hook
-
0.6
49.
49c
25
Caliper (0.4 mm)
Large smooth
alligator forceps
Small smooth
alligator forceps
26
SO.
SOd
Chorda tympani
Jomt knife
Crurotomy
scissors
2.5 mm Hook
Tympanoplasty
SOb
Removal of the Stapes Suprastructure
With the prosthesis in place, the incudo-stapedial joint is
separated with ajelnt knife (Fig. 5Oa). the stapedial tendon
is sectioned with tympanoplasty microscissors (Fig. 50 b),
the posterior crus is cui with cruratamy scissors that are
controlled with both hands (Fig. 50 c), and the anterior crus
is crushed at the level of the footplate with a 2.5 mm, 45
hook (Figs. 50 d and e).
The stapes arch is removed, and final mobility of the ossi-
cular chain is confirmed. There should be no free move-
ment of the prosthesis loop when either the incus or
malleus is moved (Fig. 50 f) ,
50e
----.
1.5 mm Hook

Tempo
50.
Sealing
Repast'
Three c
sion are
Venous
prior to
the ova
is repoli
in corti
(Fig. 52
52
1.5 mm Hook
Sealing of the 5tapedotomy Opening and
Repositioning of the Tympanomeatal Flap
Three connective tissue pledgets from the endaural inci-
sion are placed around the stapedotomy opening (Fig. 51 a)
Venous blood obtained from the cubital vein of the patient
prior to surgery and one drop of fibrin glue are used to seal
the oval window niche (Fig. 51 b). The tympanomeatal flap
is repositioned, and two small Gelfoam pledgets soaked
in corticosporin are used to keep the flap in poSit ion
(Fig. 52).
52
51b
510
Venous
blood
Fibrin
"""
.' " ," .
' ,''''
. -' " , '
Gelfoam and ' 0,
Ot
"
ospofln ";'
,

.
" ,
o
o
o
o ::::;: .. ..
" .. .. , , .
'1":-
, , "
"
".
;:;"
.' ,

, .
" ,
" .

'"
" '

.' .

.. '
,. "
27
28
53

...

'.
'.
'.
------
c
C.2 MalleoStapedotomy
Endaural Approach
This surgical step is identical to incus stapedotomy (Fi g.
423, page 22).
Tympanomeatal Flap
The tympanomeatal flap used for malleo-stapedotomy is
larger than that described for incus-stapedotomy. The pos-
terior limb (C-B. Fi g. 53) is the same, but the anterior limb
(D-B. Fi g. 53) extends to 4 o' clock on the right side and
8 o'clock on the left.
The soft tissues are elevated from the underlying bone
using a Key raspatory. At this stage, the endaural retractors
are replaced to obtain maximal exposure without injuring
the skin margins (this surgical step does not apply to the
temporal bone). The tympanomeatal flap is raised from the
underlying bone with a Fisch microraspatory and a micro-
suction tube (Fi g. 15, page 10). In Figure 54, the anterior
and posterior tympanic spines are exposed for anatomical
demonstration. In reality, the tympanomeatal flap should
not be separated from the Incisura tympanica Rlvini before
55
A
54
Spina tympani
anteoor
Spina tympani
posterior
\
c
D
completmg the canalplasty to avoid contamination of the
middle ear cavity with contaminated saline solution used
for irrigation while drilling.
Antero-superior Canalplasty
The canal skin is elevated from the wall of the ear canal
with a Fisch microraspatory. The antero-superior overhang
of bone is then removed with sharp and diamond burrs
until the anterior and posterior tympanic spines can be
identified (see also Fig. 43 b, page 23). The tympanomeatal
flap should remain attached to the bone at the entrance of
the middle ear until drilling is completed to avoid contami-
nating the cavum tympani with irrigation fluid.
Elevation of the Tympanomeatal Flap
The tympanameatal flap is first elevated from the posterior
tympanic spine using a left Fisch microraspatory (right ear)
that is introduced under the rim of bone lateral and superi-
or to the chorda tympani. The Shrapnell membrane is then
elevated from the malleus neck and lateral malleal process
until the anterior tympanic spine and the beginning of the
anterior tympanic annulus become visible.
Antenor
malleal
ligament
Spona tympani
posterior
56
Antenor maBeal process
Lat"""
malleal
process
ho,,'; tympani

"""
"'.
...... .,

,

, . '.
'

,
,
,
,

57.
Exposu
The con
by
the
ing stnJ(
Pyral
Oval
laint

Inferi
Later
Antel
Antel
The can
ble. Rer.
the oto/(
Mallei
, .. --

,

58b

,
,
57.
Antenor tympanIC
""M
M
I
Exposure for Malleo-Stapedotomy
Pyramidal
process
The correct exposure for malleo-stapedotomy is obtained
by using a curette to enlarge the supero-posterior edge of
the bony external canal (see Fig. 44, page 23). The follow-
ing structures should be exposed (Fig. 57 b):
Pyramidal process with the stapedial tendon
Oval window with the stapes and incudo-stapedial
Joint
Tympanic segment of Fallopian canal
Inferior part of the incudo-malleal loint
Lateral malleal process and malleus neck
Anteri or malleal process and ligament
Anterior tympanic spine
The corda tympani should be kept intact whenever possi -
ble. Remember that an intact chorda is the calling card of
the otologist.'
Malleus nipper
58b
Incudo
malleal
jOint
57b
Antenor malleal process
Removal of Incus and Malleus Head
29
The malleo-stapedotomy is performed when there is total
or partial fixation of the malleus and/or incus. A fixed incus
is removed after cutllng its loog process with a malleus
nipper to avoid damage to the chorda tympani during
extraction (see also Fig. 35 c, page 18). The malleus nipper
is not used to section the malleus neck because this
maneuver would leave the anterior malleal process intact
(Fig. 58 b).
CalCi fied anterior
malleal ligament
30
: ::::::-
59
A fixed malleus head is removed most effectively by cutting
Its neck with a 0.6 or 0.8 mm diamond burr (Fig. sac).
While drilling. the malleus handle is held with a large
toothed straight alligator forceps controlled by the left
hand. The drilling starts over the anterior matleal process,
which is just anterior to the lateral process (Fig. SSe) and
continues in a superior and antero-poslerior direction
across the malleus neck. This C shaped line of drilling per-
mils the anterior malleal process to be included in the
resection. Great care is taken to keep the chorda tympani
intact. The chorda tympani runs under the anterior malleal
process from which it must be separated by using a hook
prior to drilling.
Preparation of the Stapes Prosthesis
The previously mentioned Titanium Stapes Prosthesis,
0.4 mm diameter and 8.5 mm length, is used for both
incus-stapedotomy and malleo-stapedotomy. The initial
steps for preparing the prosthesIs are the same for both
types of stapedotomy (see page 24). The average distance
between the proximal malleus handle and the stapes foot-
plate is 6.5 mm (including 0.5 mm to allow for protrusion of
the piston into the vestibule). The Titanium Stapes
ProsthesIs is trimmed on a titanium cutting block (Fig. 59).
The surface of the cutting block should be humidified with
saline solution to eliminate unnecessary movement of the
prosthesis. The diameter of the prosthesis loop is enlarged
to the size of the malleus handle by moving it along a
1.5 mm, 45
0
hook with watchmaker forceps and then
stored in the 0.4 mm hole of the cutting block.
Shapin9 of Prosthesis-Shaft for the Mal1eus Handle
The shaft of the prosthesis may be bent along various
planes on the cutting block to accommodate the anterior
position of the malleus. This is done while the prosthesis is
in t he 0.4 mm hole of the cutting block by gently bending it
to the correct extent by pushing the shaft with watchmaker
forceps (Fig. 60). This same maneuver can be performed in
a lateral direction if required by t he steep position of the
malleus handle.
60

-
Tempora
Perloral
This stel
InCUs-5tl
cial caSE
Removil
The star
plate. B
Fig. SOl
insure Sl
fntrodu(
The pick
middle e
my (see
tymparn:
such the
visible w
is first pi
bend arE
dicular I
introduc
lateral st
Fixation
The prO!
distal to
the dfUl
Cnmpln,
uSing la
forceps
The pro!
Sealing
of the T:
These s
(see Fig

Perforation of the Footplate
This slep is performed using manual perforators as for an
incus-stapedolomy. An Erbium-YAG laser is used in spe-
cial cases (e.g. mobile foot plate).
Removal of Stapes Arch
The stapes arch is removed after perforation of the loot-
plate. Both crura are cut using crurotomy scissors (see
Fig. 50 c, page 26). The stapedial tendon is cut last to
insure stability while cutting the crura.
Introduction and Fixation of the Stapes Prosthesis
The picking up and the introduction of the prosthesis in the
middle ear are done in a manner similar to incus-stapedoto-
my (see Fig. 49, page 25). The exposure given by the large
tympanomeatal flap and the anterosupet'lor canalplasty is
such that both, the malleus handle and the footplate are
visible with one position of the microscope. The prosthesis
is first placed on the footplate to ensure that the length and
bend are adequate (the prosthesis cylinder must be perpen-
dicular 10 the foot plate). The prosthesis cylinder IS then
introduced into the vestibule for 0.5 mm (measured from the
lateral surface of t he footplate) using a 1 mm, 45hook.
Fixation of Stapes Prosthesis
The prosthesis loop is attached to the malleus handle just
distal to the lateral malleal process (Extensive separation of
the drum from the malleus handle should be
Crimping the prosthesis to the malleus handle is performed
uSing large (Fig. 61 a) and small smooth straight alligator
forceps (Fig. 61 b). Each forceps is held with both hands.
The prosthesis loop should be immobile after crimping.
Sealing of the Stapedotomy Opening and Repositioning
of the Tympanomeatal Flap
These surgical staps are done as for incus-stapedotomy
(see Fig. 51, page 27).
Titanium stapes
prostheSIs
(0.4 mm diameter)
."
Titanium stapes
prosthesis
(0. 4 mm diameter)
" .
31
32
62
MC'
Dura
63
64
1
Sigmoid SinUS
RetrOSlgmold
cells
Digastric
muscle
o Open Cavity (Open Mastoido-
Epitympanectomy or Open MET)
The surgical principles of an open MET are:
<D rad/cal exenteration and
CD adequate exteriorization
of the pneumatic cell tracts. In clinical sit uations, the open
MET is often associated with partial obliteration of the cav-
ity using an occipital myosubcutaneous flap (METQ. or
Mastoidectomy, Epilympanectomy, Iympanoplasty and
Qbliteration with myosubcutaneous flap). The first steps of
an open-cavity procedure (Retroauricular Skin Incision and
Canalplasty) are the same as for a closed-cavity tympano-
mastoidectomy. If two temporal bones are used for the dis-
section, the bone available for performing the open-cavity
procedure was already used for the incus- and malleo-
stapedotomy. Therefore, a modified meatal skin flap must
be used for the canalplasty.
Checklist for Bone Work In Open MET
The recommended sequence of bone removal for an open
MET is (Fig. 62):
<D Wide lateral bone removal over the root of the zygoma
with skeletonization of the middle cranial fossa dura
and sigmoid sinus, exposure of digastric muscle, and
skeltonizallOn of stylomastoid foramen.
Identification of the tympanic segment of the fallopian
canal and posterior bony semicircular canal, and low-
ering of the facial ridge.
CD Radical exenteration and extenonzation of the retrofa-
cial. retrolabyrinthine and the retrosigmoid cells.
<D Radical exenteration and exteriorization of the epitym-
panum (supral abyrinthine and supratubal recesses).
Extended antero-inferior cana/plasty.
0.1 Mastoidectomy
Lateral Bone Removal
Mastoidectomy begins with wide removal of lateral bone
from the zygomatic arch to the sinodural angle (Fig. 63).
The dissection is continued with skeletonization of the mid-
dle cranial foss dura, the sigmoid sinus and sinodural
angle. The lateral semicircular canal is identified in the
antrum and the lateral surface of the digastriC muscle is
exposed (Fig. 64).
Epitympanotomy
The antrum is opened and the dissection is extended ante-
riorly to periorm an epitympanotomy (Fig. 64 and Fig. 28,
page 15). The tympanic segment of the facial nerve is iden-
tified at t he inferior edge of the lateral semicircular canal
(see also Fig. 32, page 17). The bone at the mastoid tip
covering the lateral suriace of t he digastric muscle is
removed. No bony overhangs along the dissection field
should remain (particularly over the middle cranial fossa
dura and behind the sigmoid sinus).
,

56
Mastoi,
The SUI
muscle
are visll
bone a
remove
stylom::
{see F i ~
Lowenl
Th' po
essentu
lion of
nerve (F
CD the
the
and
<D the
The ani
to fully.
Comph
The inc
and m ~
pres8fV
preserv
retrolat
exenlaf
Ionized

65
Stylomastoid
foramen
Stylomastoid
periosteal
fibres
Mastoid Tip Surgery and Facial Nerve Identification
The superior edge and the lateral surface of the digastric
muscle is followed until the stylomastoid periosteal fibers
are visible. The stylomastoid foramen is identified and the
bone along and lateral to the white periosteal fibers is
removed (Fig. 65). At this stage, a crack forms lateral to the
stylomastoid foramen, mobilizing the remaining mastoid lip
(see Fig. 71 , page 35),
Lowering of the Facial Ridge
The posterior semicircular canal is identified. The three
essential landmarks are now visible, determining the posi-
tion of the mastoid and pyramidal segments of the facial
nerve (Fig. 66). These are:
ill the tympanic segment of the facial nerve
<D the inferior edge of the posterior semicircular canal,
and
<D the stylo-mastoid foramen .
The anterior remnant of the superior canal wall is removed
10 fully expose the ossicular chain .
Completion of Mastoidectomy
The incus is disarticulated from the stapes, and Ihe incus
and malleus are removed. If the malleus handle can be
preserved, the tensor tympani tendon should also be
preserved to stabilize the latter. The retrofacial (1), the
retrolabyrinthine (2) and the retrosigmoid (3) cel l t racts are
exenterated and exteriorized. The jugular bulb is skele-
tonized (Fig. 67: Inserts a and b)
/
66
2
67
67.
TympaniC segment
of facial nerve

::.- fOl"amer1
67.
33
of
canal
34
,
68
70
Sinus epitympani
' .........
69
0.2 Epitympanotomy
Epitympanotomy
The supralabyrinthine (3) and supratubal (4) recess are
exenterated and exteriorized to expose the ampullary end
of the lateral and superior semicircular canals (Fig. 68). The
awareness of the close proximity of the labyrint hine and
tympanic segments of the facial nerve prevents injury of
the geniculate ganglion (5).
0.3 Completion of Mastoido-
Epitympanectomy
Exteriorization of Antero-Superior Cavity
An extensive antero-inferior canalplasly is per10rmed to
remove all bone overhangs at the root of the zygomatic
arch (Fig. 69: Insert). The tympanic bone should be low-
ered to meet the level of the stylomastoid foramen (6).
A diamond burr is used when neanng the mandibular
condyle while watching for color changes that indicate its
proximity.
New Tympanic Sul cus
If there is no remnant tympanic annulus, drill a new tym-
panic sulcus (Fig. 70, (7)) in the bony canal wall from the
1 to 9 o'clock poSItions (right side). The resulting bony
ledge will accommodate the fascial graft used for myringo-
plasty. The profile and position of the new ledge are shown
in the inserts shown in Figure 70.
If an anterior tympanic membrane remnant is present, the
new sulcus is performed from 4 to 9 o'clock because t he
tympanic annulus is left in situ along the sacred anten'or
tympano-meatal angle (see Fi gs. 25, 26 and 36).
\
\
I
I
Tempor
"
Mastoid
The mru
ture line
foramen
to latera
the soft
toid tip.
E.1. T
General
This typ
an intac
ic memt
used. If
",",0"'"
bone; i.E
aerated
General
Myring(
A thick
preser"IC
die ear
(Fig. 72-
A fresh
ratory) i:
ic mem
sulcus
segmel'
The sla
fascia ((
low, a ~
used to
I
I
I
)
71 72a
Mastoid Tip Removal MicrosuClIOn N' 2
The mastoid tip is removed with rongeurs along the frac-
Ge/film or
thick silastic
ture line produced during identification of t he stylomastoid 2.5 mm. 4 5 ~ Hook
foramen (see Fig. 72 a). The rongeur is rotated from medial
to lateral, and a large curved scissors is used to separate
the soft tissues attached to the undersuriace of the mas-
toid tip.
E. Tympanoplasty (Myringo- and
Ossiculoplasty in Open Cavities)
E.l. Type III Tympanoplasty
This type of reconstruction is periormed in the presence of
an intact mobile stapes. If a portion of the anterior tympan- 72b
ic membrane remains intact, an anterior fascial underlay is
used, If no tympanic membrane is left, an overlay graft
becomes necessary (an overlay being a graft placed over
bone; i.e., over the old or new tympanic sulcus. limiting the
aerated middle ear space: see also B.3. 1. Myringoplasty,
General Consi derati ons, page 19).
Myringoplasty with Anterior Fascial Underlay
A thick (1 mm) Silastic sheeting (Gelfilm fM is used in the
presence of an active infection) is introduced into the mid-
dle ear up to t he tympanic ost ium of the eustachian tube
(Fig. 72a).
A fresh temporalis fascia (a wet piece of paper in the labo-
ratory) is placed under the anterior remnant of the tympan-
ic membrane (underlay grafting) over the new tympanic
sulcus inferiorly. and over the facial ridge and tympanic
segment of the fallopian canal postero-superior (Fi g. 72 b).
The stapes head should be higher than the surrounding
fascia (outward bulging. Fi g. 72 c). If the stapes head is too
low. a piece of tragal or conchal cart ilage with a notch is
used to increase its length.
",
New Tympanic
Sulcus
35
36
73.
74. 74b
Holding forceps
740
Blood or
"".. ___ .... , fibrin glue
74<1
Temporalis
Fascia
73b
When the tympanic membrane is absent, a thick (1 mm)
Silaslic sheeting is introduced into the middle ear to avoid
scar tissue formatIon between the fascia and mucosa
(Fig. 73 a). The fresh temporalis fascia (or tragal perichon-
drium) is then placed over the circumferential new tympan-
ic sulcus, the tympanic segment of the fallopian canal and
the semicanal of the tensor tympani muscle (overlay graft-
ing) (Fig. 73 b),
E.2 Total Reconstruction of the
Ossicular Chain
E.2.1 The Fisch Titanium Total Prosthesis
E.2.1.1 Preparation of Prosthesis
The Fisch Titanium Total Prosthesis (FTTP) is composed of
an L-shaped shaft with head and a shoe (foot) with spike
(Fig. 74 a, b). The distance between the tympanic mem-
brane and the footplate is determined with the malleable
measuring rod. The FTTP can be used with or without the
shoe.
Prosthesis with Shoe
If the shoe IS used, 0.5 mm should be subtracted from the
total measured length to account for the additional length
of the shoe in the assembly.
The FTTP shaft is introduced in the 0.6 mm hole of the
Titanium Cutting Block (see Fig. 59) and trimmed to the
desired length (Fig. 74 a). The foot is placed into the
1.0 mm hole of the cutting block (Fig. 74 b). The F I I P shaft
is grasped with a special curved holding forceps and intro-
duced into the shoe (Fig. 74c). A drop of blood or fibrin
glue can be used to increase the stability of the assembled
prosthesis (Fig. 74 d).
If more strength is required, a special crimping forceps can
be used to squeeze the foot tightly to the shaft.
Tempora
Prosthe
Them
narrow c
is also u
inner eal
in the ve
shaft is (
81 , pagE
E.2.1.2
Angulat
The thie.
the plan
drum pc
75a and
Size anc
The m
Special
meier of
one or 1\
It is alsc
thesis hI
It any dE
7 ..
7&
Prosthesis with Cartilage Disc
The mp is used without a shoe if the oval window is too
narrow or the stapes arch remains in place, The shaft alone
is also used if the patient does not accept the risk to the
inner ear deriving from the introduction of the shoe's spike
in the vestibule. If the shoe is not used, stabilization of the
shaft IS obtained by using a cartilage disc (see Figs. 80 and
81 , pages 39, 40).
E.2.1.2 Shaping the Prosthesis Head
Angulation
The thickness of the FTIP head is only 0.1 mm. Therefore.
the plane of the prosthesis head can be adapted to the
drum position in the vertical and horizontal planes (Figs.
75a and b).
Size and Shape
The mp head is 0.' mm thick and 5 mm in diameter.
Special titanium scissors can be used to reduce t he dia-
meter of the prosthesis head to 3 or 4 mm by cutt ing away
one or two outer rings (Figs. 76a, b and c).
It is also possible to remove the anterior half of the pros-
thesis head (when the malleus handle is present) or to give
It any desired shape (Fi g. 76 d).
5mm
76.
3mm

76c
75.
75'
76'
7'"
4

1
Vertical plane
Hanzontal plane
, mm
..

:
r
I>
\

~
?

Scissors for titanium
total prothesis
37
.

38
'70
77,
,.
0
00
0
0 <>0 <>
77'
77'
Holding
forceps
length of L-shaped Arm
Another unique feature althe FTTP is the ability to change
the length of its l-shaped arm to meet the specific require-
ments of the middle ear anatomy. particularly when the
prosthesis head is reduced in size. For this purpose, the
FTTP is grasped with two watchmaker forceps and
straightened, then bent in the deSired angle as shown in
Fig. 77 a-d.
E.2.1.3 F I I P Handling
Holding Forceps and Microsuction Tube
The FTTP is transported from the cutting block to the
middle ear with special curved holding forceps or with the
largest microsuction tube.
_ Mk:rosuction
,"be
Tempora
, ..
Rotalier
The 1001
part of t
position
held in II
manipul.
using on
the pros
ducing c
tension t
79a ana
cartilage
moveme

connectl
'.'
n'
.' ."
, I
'" I'
.,'
'e
(;)
90a


,
79.
Rotation of the Head of F I I P under the Drum
The loot of the FTIP is fixed with the spike on the central
part 01 the footplate. The FTIP head is then rotated into
positioo by raising the pars tensa with a 2.5 mm. 45" hook
held in the left hand, while a second hook (1.5 mm, 45") IS
manipulated by the nght hand to rotate the prosthesis head
using one of its multiple central holes. The final position 01
the prosthesis head is under the central pars tensa, pro-
ducing a slight bulging of the latter as a sign of sufficient
tension to keep the prosthesis in the deSired position (Figs.
79 a and b). There is no need to cover the prostheSis with
cartIlage because the prosthesis head can follow the
movements 01 the tympanic membrane because 01 the
flexibility of the 0.2 mm diameter angled titanium band
connecting it to the shaft.
''''
Stabilization of the F II P on the Stapes Footplate.
Use of Shoe with Spike
39
The best stabilization of the FTIP to the foot plate is
achieved by perforating the central part 01 the stapes loot-
piate to allow introduction of the 0.3 mm long spike of the
prosthesis shoe (Fig. 80 a). The perforation is made with
the smallest manual perforator. A mobile footplate is fixed
during this maneuver with a 1.0 mm, 45" hook held in t he
left hand, which pushes the foot plate slighty against the
margin of the oval Window. An Erbium-VAG laser can also
be used to perforate a mobile footplate. Usually one single
pulse of 35 mJ is sufficient for this purpose.
Tragal cartilage
f... ~ Tragal cartilage
,

,"
f ',.
"
I
,
I
,'I
"
, I
~
'/
80.
/
I ,
, '"
" . ..
II
., ,I.
., '
, ' , . , ~

.,.1
. ,-
.' I
' "
"h
-,'
,
80b
o
,
,
,
~ , . , ~
,
,
,
' .
,
.,.1 ,
,
. ,-
,
.' I'
,
,
"
,
o!\ ,
, -,
,
,
,
,
,
,
SOc

40
Endaural
skin InciSIOn
81.
81.
81,
___ Anatomical
forceps
Special holding
forceps
81b
8"
8"
0.6 mm
diamond burr
} , mm
3mm
Shaft without Shoe
Nearly equal functional results have been obtained by plac-
ing the shaft of the FTTP without a shoe on the footplate.
In this situation, however; a cartilage disc of 1 mm thick-
ness obtained from the tragus or from the conchal cartilage
must be used for stabilization. The cartilage disc has to fit
tightly within the oval window niche. The technique used
for the harvesting and preparation of the cartilage disc is
shown in Figs. 81 a-g.
When the stapes arch is intact, the F II P is a/so used with-
out a shoe. In this case, the stabilization is achieved by
wedging small pieces of cartilage (from the tragus or con-
cha) between the wall of the oval window niche and the
prosthesis (Fig. SOc).
Temporal
E.2.2 F
General
This tech
stapes a
another t
has farlec
malleus r
at an inle
First Sla
A piece
endaural
pedehan.
diameter
is introcll
two sma
handle, 9
The perie
duced UI
and IS ar
clock
cus. The
graft bet
nameala!
oval wine
Second :
The secc
if no Slgr
nameala'
implantec
various 9
SIS. Only
superior
excessivl
desired I
(using m,
(fixed or I
The Titan
duced O.
the vesll
usingsm
stapedot,
pledgels.
glue (see
,

E.2.2 Fisch Titanium Neo-Malleus
This technique is utilized In absence of malleus, incus and
stapes arch, when the stapes footplate is fixed or when
another type of total reconstruction of the ossicular chain
has failed to improve the function of a mobile stapes. Neo-
malleus reconstruction is usually performed In two stages
at an interval of three to six months,
First Stage
A piece of tragal perichondrium is obtained through the
endaural approach (Figs. 61 a--c). A rectangular piece of
perichondrium is cut slightly longer than the supero-inferior
diameter of the drum. The 5 mm long titanium neo-malleus
is introduced over the lateral surface of the graft through
two small incisions (a No. 11 blade with rounded scalpel
handle, graft on glass platform IS used) (Figs. 82 a, b).
The perichondrium with the attached neo-malleus is intro-
duced under the partially elevated tympanic membrane
and is anchored inferiorly through the gap created at 6 0'
clock (right side) between the tympanic annulus and SUl-
cus. The perichondrium will rest superiorly as an overlayed
graft between the superior canal wall and the tympa-
oomeatal flap. The titanium neo-mal/eus is aligned over the
oval window (Fig. 82c).
Second Stage
The second stage is performed three to six months later
if no signs of tubal dysfuction have appeared. The tympa-
rlOmeatal flap is elevated and the superior end of the
implanted neo-malleus is identified. The neo-malleus has
various grooves for fixation of the loop of a stapes prosthe-
sis. Only one of these indentations and not the complete
superior end (as shown in the picture) is exposed to avoid
excessive movement and 10 keep Ihe neo-malleus in the
desired position. A 0.5 mm stapedotomy is performed
(using manual perforators or a laser) in the center of the
(fixed or mobile) footplate (Fig. 83 a).
The Titanium Stapes Prosthesis is brought into place. intro-
duced 0.5 mm from t he lateral surface of t he footplate in
the vestibule, and crimped on the titanium neo-malleus
using smooth small straight alligator forceps (Fig. 83 b). The
stapedotomy hole is sealed with three connective tissue
pledgets, venous blood from the cubital vein, and fibrin
glue (see Stapedotomy Figs. 51 a-c, page 27).
82.
820
82,
83b
Stapes only
(Ii_ad or mobile)
41
42
Supra tubal cells
Supra
Jabynnthlne
cells
I
Retro-
I
84

F Additional Temporal
Bone Dissection
Eustachian t ube
. Pericarolld celts
Internal
carotid ar1ery

Retrolacial cells
Retrosigmoid cells
Additional temporal bone dissections may be carried out at
the end of the procedure. They represent a transition from
temporal bone to lateral skull base surgery.
In the authors' opinion, these dissections belong within the
curriculum of a modern otologist. who in fact should not
remain a middle ear surgeon, but become a temporal bone
surgeon.
F.1 Subtotal Petrosectomy (SP)
The principle of SP is "the complete elimination of the
pneumatic middle ear cleft associated with the permanent
occlusion of the isthmus of the eustachian tube
W
The cavi-
ty may be left open or be obliterated (with pedicled muscle
flaps or free abdominal fat grafts). In the latter case, the
EAC is closed in two layers as a blind sack.
There are two types of subtotal petrosectomy, one with
OfesecvatlQQ the other with removal of the otic capsule
(For more details see: "Microsurgery of the Skull Base
ft
U. Fisch and D. Mattox, Georg Thieme Stuttgart New York
1988).
F.1.1 Subtotal Petrosectomy with
Preservation of the Otic Capsule
This operation is is per10rmed to remove extensive
ral bone cholesteatomas, adenomas, extensive facial
nerve neuromas, angiomas and Class B paragangliomas. It
is also used to seal congenital CSF leaks and Ihose of a
Lateral
semiCircular
"'"'"
Supenor
semiCircular
canal
85
GeniCulate
gangioo
Internal carot id
.rt"Y
Jugular
bulb
Posterior
semicircular
canal
traumatic nature (e.g., following transverse fractures of the
temporal bone). to introduce CI in sclerotic temporal
bones, or when there is a meningitiS risk due to a possible
CSF leak.
Exenteration of Pneumati c Cell Tract s
The cell tracts of the middle ear cleft (Fig. 84) are exenter-
ated in the follOWing order: retrosigmoid, retrofacial.
labynnthine, supralabynnthine, supratubal. infralabyrinthine
and pencarotld.
Most of these cellular tracts have been dealt with when
per10rming an open MET.
In fact. an procedure performed according to
the authors' surgical principles is a
my," with the exception of the infralabyn'nthine and
carotid cells that are left intact.
Surgical site following exenteration of pneumatic cell
tracts and preservation of the otic capsule
The pneumatic cell tracts of the temporal bone (with the
exception of the apical) are removed (Fi g. 85). To make
sure that no cells are left behind, the jugular bulb and the
vertical Intra temporal carotid artery are skeletonized.
The tympanic segment of the facial nerve is also
tonized until the geniculate ganglion and the greater super-
ficial petrosal nefVe are identified. Note that the
labyrinthine segment of the faciat nerve is medial to and
covered by its tympanic segment. and that the proximal
tympanic segment and the geniculate ganglion form a
der between the supratubal and supra labyrinthine
es. The otic capsule and, therefore, inner ear function are
preserved.
Peri carotid cells and obliteration of the eustachian tube
The vertical segment of the intratemporat carotid artery
(ICA) is exposed to the bend indicating the beginning of the
horizontal segment Note that the isthmus of the
an tube is below and anterior to the ICA. The semicanal of
the tensor tympani muscle covers part of the posterior
aspect of the horizontal segment of the ICA. Remember
that the ICA may be dehiscent along the medial wall of the
Tempor
prolymp<
can exle
may reql
pericarot
eustachi;
F.1.2
F
General
The otic
situated
(e.g., SUI=
teatomas
2,Di 1-2)
part of II'
associatE
with rem
approacl"
Hilselbert
base, Arc
removal c
nerve, Ie.
details Of
sule, see
Thieme :::
with rem<
fore, reql
Remova
The sem
rinthine a
The
must be
the
the sup
labyrinthi
anterior a
auditory
canal is
(Fig. 88).
Temporal Bone Dissection - The Zurich Guidel ines
protympanum (Fig. 86). The anterocarotid pneumatic cells
can extend into the pyramid apex, and their exenteration
may require precise work with a diamond burr. When all
pericarotid cells are exenterated, the isthmus of the
eustachian tube is ready for obliteration with bone wax.
F.1.2 Subtotal Petrosectomy with
Removal of the Otic Capsule
The otic capsule is removed to gain access to lesions
situated along the medial aspect of the inner ear spaces
(e.g., supralabyrinthine and infralabyrinthine-apical choles-
teatomas, and temporal paragangliomas class C3-4 Del-
2,Oi 1-2). The SP with removal of the otic capsula is also
part of the transotic approach used for acoustic neuromas
associated with a total loss of hearing. Remember that SP
with removal of the otic capsula is not a transcoch/ear
approach. The transcochlear approach (House WF,
Hitselberger WE: The transcochlear approach to the skull
base, Arch Otolaryngol 1976, 102: 334-342) coosists of the
removal of the cochlea and posterior rerouting of the facial
nerve, leaving the middle ear and fAG intact. (For more
details 00 the SP with and without removal of the otic cap-
sule, see Fisch U. Mattox D: Microsurgery of the Skull Base,
Thieme Stuttgart and New York 1988). Lesioos requiring SP
With removal of the ollc capsula involve the dura and, there-
fore, require obliteration of the pneumatic middle ear cleft.
Removal of the Posterior Otic Capsula (Labyrinth)
The semicircular canals are removed as in a trans/aby-
rinthine approach (Fi9. 87).
The tympanic and labyrinthine segments of the facial nelVe
must be watched. Removal of the cochlea continues until
the medial wall of the vestibule, the posterior ampullary and
the superior ampullary nelVe become visible. The
labyrinthine segment of the facial nelVe is identified 2 mm
anterior and 2 mm lateral to the superior edge of t he internal
auditory canal. The posterior wall of the internal auditory
canal is skeletonized to the porus acousticus internus
(Fig. 88).
Isthmus of Eustachian tube
86
Semlcanal of the
tensor tympani m.

Oehiscent internal carotid artery
GenICulum of
facial nerve
Supralabyrinthlr"18
...,'"
Labynnlhlr"18 _
segment ...
01 facial nerve
87
Supratubal recess
Tympanic segment
of facial nerve
43
44
Medial wall
of vesllbule
Labyrinthine
,..menl
ollacial nerve
..
Internal
auditory
canal
Internal
audltOfY
_I
Middle
cranial
fossa dura
89

Petrosal nerve
Apical turn
of cochlea
Middle turn
of cochlea
Basal turn
of cochlea
Posterior
ampulla!)'
nerve
Posterior fossa dura
Horizontal segment
of ICA
Isthmus of Eustachian tube
VertiCal segment
of ICA
Carotid
foramen
Jugular
bulb
Removal of the Anterior Otic Capsula (Cochlea)
Sketetonize the mastoid segment of the facial nerve and
the jugular bulb. Follow the lugular bulb as far as possible
medial to the facial nerve toward the round window niche.
Remove the bone covering the basal, middle and apical
turn of the cochlea (the apical turn may be covered by the
semicanal of the tensor tympani muscle) working anterior
to the facial nerve (Fi g. 68). Skeletonize the inferior and
anterior walls of the internal auditory canal until you reach
the anterior porus. Note that the internal auditory canal is
situated deep and antenor to the skeletonized tympanic
and mastoid facial nerve.
Expose the posterior fossa dura between the internal audi-
tory canal, superior petrosal sinus (medial to t he semicanal
of the tensor tympani muscle), vertical carotid artery, and
jugular bulb (Fig. 89). Opening this dura would lead in the
anterior cerebello-pontine angle. This is what is done in the
transotic approach. which is the only approach permitting
the surgeon to first separate the intracranial segment of the
facial nerve from the anterior pole of the tumor.
Final surgical site of SP with removal of the otic capsula
The complete medial wall of the temporal bone is
exposed between Sigmoid sinus, superior petrosal sinus
(separating dura of the middle and posterior cranial fos-
sa), internal carotid artery and Jugular bulb. The cell
tracts located medial to the otic capsula and extending
toward Ihe pyramid apex have been completely exenter-
ated (Fig 89).
P,,""o' G Suggested Reading
ampulla!),
(Singular) nerve
/"-..1' Posterior fossa dura
Sigmoid sinus
The following books and papers contain detailed informa-
tion on the microsurgical techniques presented in this
manual:
Books
U. FISCH in collaboration with J. MAY: Tympanoplasty.
Mastoidectomy. and Stapes Surgery. (1" edition, 1994,
Cl Georg Thieme Stuttgart - New York).
U. FISCH, J. MAY, 1. LINDER: Tympanoplasty,
Mastoidectomy, and Stapes Surgery. (2"" edition, forth-
coming 2006; approx. 320 pp, 36 tables, approx. 155 illus-
trations, hardcover. ISBN 158890167x I 3t3t37702x;
C Georg Thieme Stuttgart - New York).
A. POSADA: Spanish translation of Tympanoplasty,
Mastoidectomy and Stapes Surgery 1998
A. POSADA: Spanish translation of the Course Book of the
Fisch International Microsurgery Foundation. 2002
U. FISCH, D. MATIOX: Microsurgery of the Skull Base,
1988 10 Georg Thieme Stuttgart - New York, 2000
Thieme Classic Edition
R. POSADA: Spanish edition of Microsurgery of the Skull
Base 1998
Tempora
Papers
U. FISC
Lateral :
LaryngOl:
HOUSE
approacl
342, 197
FISCH U
in Rev;
Neurolol
HUBER ,
Oamagir.
22:311-
NANOAF
The Ar
Otosclen
KWOK f
Surgery:
the L o n ~
and OiffE
295, 200
HUBER
FISCH I
Diagnosi
Surgery.
348- 35
FISCH U
L-shapel
the Ossie
2004
H.1 f
I
H.2 f
1
,
Papers
U. FISCH. PH. CHANG, TH. LINDER: Meatoplasty for
lateral Stenosis of the External Auditory Canal, The
laryngoscope 112: 1310-1314, 2002
HOUSE WF, HITSELBERGER WE: The transcochlear
approach to the skull base, Arch Ololaryngol: 102: 334-
342,1976
FISCH U., OEZBILEN G.A. , A. HUBER: Malleostapedotomy
in Revision Surgery for Otosclerosis, Otology &
Neurotology, 22:776-785, 2001
HUBER A. , LINDER T. and FISCH U.: Is the Er: Yag Laser
Damaging to Inner Ear Function?, Otology & Neurotology,
22: 311-315, 2001
NANDAPALAN V., POLLAK A., LANGNER A. and FISCH U.:
The Anterior and Superior Malleal Ligament s in
Otosclerosis, Otology & Nerotology, 23: 854 - 861, 2002
KWOK P. , FISCH U., STRUTZ J. and MAY J.: Stapes
Surgery: How Precisely Do Different Prostheses Attach to
the Long Process of the Incus with Different Instruments
and Different Surgeons?, Otology & Nerotology, 23: 289-
295,2002
HUBER A., KOIKE T., NANDAPALAN V., WADA H. and
FISCH U.: Fixation of the Anterior Mallear Ligament:
Diagnosis and Consequence for Hearing Results in Stapes
Surgery, Annals of Otology, Rhinology & Laryngology, 112:
348 - 355, 2003
FISCH U., MAY J., LINDER TH. and NAUMANN I.C.: A New
L-shaped Titanium Prost hesis for Total Reconst ruction of
the Ossicular Chain, Otology & Neurotology, 25: 891 - 902,
2004
H Prostheses and Instruments
H.1 FI SCH Titanium Middle Ear
Prostheses
H.2 FISCH Special Instruments for
Tympanoplasty, Mastoidectomy
and Stapedotomy -
45
46
FI SCH Special Instruments for Tympanoplasty,
Mastoidectomy and Stapedotomy
Tempora
CD 2202
@ 2196
@ 2197
@ 792C

2134
@ 5353
CD 2080
2080

2118

2145

7933
@ 2140
@ 2130
@ 4775
@ 2240
@ 2047

2047
@ 2047

2047

2043
@ 2043
@ 2042
@ 2261
@ 2261

2263
@ 2268
@ 2254
@ 2254
@ 2254

2254
@ 2252
@ 2252
@ 2252
@ 2252

2265

2265

2265

224E
@ 224e
@ 2266
@ 226'
Temporal Bone Dissection ~ The Zurich Guidel ines 47
CD
220213 FISCH Endaural Retractor @ 226605 FISCH Manual Perforator, 0.5 mm
@ 219613 Curved Mastoid Retractor
@ 226606 FISCH Manual Perforator, 0.6 mm
(BELLUCCI), length 13 cm
@ 221 111 FISCH Small Straight Alligator Forceps,
(j) 219717 B FISCH Articulated Retroauricular smooth, (crimping forceps for stapes
Retractor prosthesis)
@ 792003 Strong Curved Scissors (MAYO) @ 221 11 0 FISCH Large Straight Alligator Forceps,
213410 FISCH Small Tympanoplasty Scissors
smooth (crimping forceps for stapes
prosthesis)
@ 535312 Small Curved Clamp (Mosquito)
@ 221201 FISCH Small Straight Alligator Forceps,
CD 208000 Scalpel Handle No. 3, length 12.5 cm
serrated
208001 FISCH Round Scalpel Handle,
@ 221 100 Large Straight Alligator Forceps,
length 14 cm
serrated (HARTMANN)

211804 FISCH Dual Purpose Scalpel Handle,
@ 221406 F Ultra Fine Biopsy Forceps
length 16 cm
(FISCH, 8 cm, 0.6 mm)
~ 214500 F Jeweler Forceps, soft spring
0
221409 Small Biopsy Forceps
793303 F Small Tympanoplasty Forceps
(VoJULLSTEIN, 8 cm, 0.9 mm)
(Tissue Forceps), toothed
@ 162020 Large Biopsy Forceps
@ 214000 F Small Tympanoplasty Forceps
(HARTMANN, 2.0 mm)
serrated

222606 FISCH-BELLUCCI Ultra Fine
@ 213011 FISCH Mastoid Raspatory
Tympanoplasty Micro Scissors
@ 477500 KEY-Raspatory (curved FREER)
@ 222603 FISCH Small Tympanoplasty Micro
@ 224003 FISCH Double End Sharp Curette
Scissors
(HOUSE, medium)
@ 222601 Large Tympanoplasty Micro Scissors
<ill
204729 FISCH Suction Tube, 1.2 mm (FISCH-BELLUCCI)

204730 FISCH Suction Tube, 1.5 mm
~
222710 FISCH Crurotomy Scissors, curved right
@ 204732 FISCH Suction Tube, 2.0 mm

222720 FISCH Crurotomy Sci ssors, curved left

204733 FISCH Suction Tube, 2.2 mm

222801 FISCH Malleus Nipper
~
204352 Suction Cannula, angular,

227525 FISCH Cutting Block for Titanium
size 0.7 mm, 7.0 cm
Prostheses
@ 204354 Suction Cannula, angular.

227527 Crimping Forceps.
size 1.0 mm, 7.0 cm for FISCH Titanium Incus Prosthesis
@ 204250 FISCH Suction Adaptor
0
227530 Holding Forceps,
@ 226101 FISCH Micro Raspatory, curved right
for FISCH Titanium Incus Prosthesis
@ 227532 FISCH Micro Hook, for transporting and
@ 226102 FISCH Micro Raspatory, curved left
positioning t he FISCH Titanium Ineus
@ 226301 FISCH Tenotome
Prosthesis
@ 226810 Joint Knife, 45, round
0
227528 Scissors,
for FISCH Titanium Total Prosthesis
@ 225405 Pick 45,16 em, 0.5 mm
@ 227526 Holding Forceps,
@ 225410 Pick 45, 16 cm, 1.0 mm for FISCH Titanium Total Prosthesis
@ 225415 Pi ck 45, 16 cm, 1.5 mm ~
227534 Diamond Burr, 1.4 mm, 7 cm

225425 Pick 45, 16 em, 2.5 mm
8
843016 Bipolar Coagulating Forceps, angular,
@ 225205 Pick 90, 16 em, 0.5 mm
tip 0.4 mm, insulated, length 16 cm
@ 225210 Pick 90, 16 cm, 1.0 mm @ 843016 F Bipolar Coagulating Forceps, angular,
tip 0.2 mm, insulated handle, non-insulat-
@ 225215 Pick 90,16 cm, 1.5 mm
ad from angle to tip, lengt h 16 em
@ 225220 Pick 90,16 cm, 2.0 mm
842016 F Bipolar Coagulating Forceps,
@ 226514 FISCH Measuring Caliper, 0.4 mm
angled tip, pointed, tip 0.4 mm, insulated,
length 16 cm (not illustrated)

226516 FISCH Measuring Caliper, 0.6 mm
@ 516013 Needle Holder, tungsten carbide
@ 226501 FISCH Measuring Rod
Inserts, length 13 cm
@ 224812 FISCH Anterior Footplate Elevator @ 227900 SHEA Vein Press, 13 cm
@ 224813 FISCH Posterior Footplate Elevator
@ 231009 FISCH Glass Cutting Board

226600 FISCH Manual Perforator, 0.3 mm

239728 Metal Tray, for 20 straight ear micro
@ 226604 FISCH Manual Perforator, 0.4 mm
instruments (not illustrated)
48
220213
CD 220213
<V 219613
@ 219717 B
219613 219717
FISCH Endaural Retractor
Curved Mastoid Retractor (BELLUCCI), length 13 em
FISCH Articulated Retroauri cular Retractor
792003 213410 535312
o 792003
213410
@ 535312
Strong Curved Scissors (MAYO). length 16 em
FISCH Small Tympanoplasty Scissors
Small Curved Clamp (Mosquito)
Temporal
o 208000
208001
211804
@l 214500 F
793303 F
@ 214000 F

I
208000
208001 211804
Scalpel Handle No, 3, length 12.5 cm
FISCH Round Scalpel Handle, length 14 cm
FISCH Dual Purpose Scalpel Handle, length 16 cm
II
I
214500 F

793303 F
@
214000 F
Jeweler Forceps, pointed, soft spring
Small Tympanoplasty Forceps (Tissue Forceps),
toothed
Small Tympanoplasty Forceps, serrated
49
50
,
i
,
,
213011 477500
@ 213011
@ 477500
@ 224003
@ 204729

204730

204732
@ 204733
Q!) 204352
@ 204354
@ 204250
3 226101
@ 226102
@-@ @-@
@
224003 204729 - 204733 204352
204354
FISCH Mastoid Raspatory, 10 mm
KEYRaspatory (curved FREER). 18 mm
204250
FISCH Double End Sharp Curette (HOUSE, medium)
FISCH Suction Tube, 1.2 mm
Same, 1.5 mm
Same, 2.0 mm
Same, 2.2 mm
Suction Cannula, angular, size 0.7 mm, 7.0 em
Same, size 1.0 mm. 7.0 em
FISCH Suction Adaptor
FISCH Micro Raspatory, 16 em, curved right
FISCH Micro Raspatory, 16 em, curved left
226101
226102
226101-226102
Tempora
Temporal Bone Dissection - The Zuneh GUidelines 51
@-@
,
,
226301 226810 225405 - 225425 225205 - 225220
@ 226301 FISCH Tenotome, 16 cm
@ 226810 Joint Knife, 45". round
@ 225405 Pi ek 45, 16 em. 0.5 mm
@ 225410 Piek 45, , 6 em. 1.0 mm
@ 225415 Pi ek 45, 16 em. 1.5 mm
@ 225425 Pi ck 45,16 em, 2.5 mm
@ 225205 Piek 90,1 6 em, 0.5 mm
@ 225210 Pi ck 90", 16 em, ' .0 mm
@ 225215 Piek90, 16em, 1.5mm
@ 225220 Pi ck 90",1 6 em, 2.0 mm
52
226514
226516
226501
226514
@ 226516
226501
@ 224812
@ 224813
~
226600
@ 226604
@ 226605
0
226606
Temporal Bone Dissection - The Zurich Gui delines
\
224812
224813
FISCH Measuring Caliper, 0.4 mm
Same, 0.6 mm
FISCH Measuring Rod, 16.5 em
226600 - 226606
FISCH Anterior Footplate Elevator, curved upward 90"
FISCH Posterior Footplate Elevator, curved downward 90"
FISCH Manual Perforator, 0.3 mm
Same, 0.4 mm
Same, 0.5 mm
Same, 0.6 mm
Tempora
-
,
,
-
-
Temporal Bone Dissection - The Zurich GUidelines
@ 221111

221 11 0
@ 221201
@ 221100
@ 221406 F

221409
@ 162020
221111
221201
221406 F
221409
= - - ~ .. -
FISCH Small Straight Alligator Forceps,
smooth, (crimping forceps for stapes prosthesis)
FISCH large Straight Alligator Forceps, smooth
(crimping forceps for stapes prosthesis)
FISCH Small Straight Alligator Forceps,
serrated
large Straight Alligator Forceps,
serrated (HARTMANN), 0.4 x 3.5 mm
Ultra Fine Biopsy Forceps (FISCH. Bern, 0.6 mm)
Small Biopsy Forceps (WULlSTEIN. 0.9 mm)
large Biopsy Forceps (HARTMANN, 2.0 mm)
53
221110
221100
162020
54
"'"'--
222606
222603
222606
~ 222603
~ 222601
S 222710
~ 222720
S 222801
@ 227525
222603
222606
222601

222710
@ _.-
222720
222710
222720
222801
FISCH-BELLUCCI Ultra Fine Tympanoplasty Micro Scissors
FISCH Small Tympanoplasty Mi cro Scissors
large Tympanoplasty Micro Scissors (FISCH-BELLUCCI)
FISCH Crurotomy Scissors, curved right
Same, curved left
FISCH Malleus Nipper
FISCH Cutting Block,
lor Titanium Prostheses

227525
Tempor
227534
Temporal Bone DIssection - The Zurich GUIdelines
227527
@
227527
@
227530
0
227532
@ 227528
@ 227526
227534 843016
0
227534
S
843016
0
843016 F
0
842016 F
e
516013
@ 227900
0
231009

227530 227532 227528
Crimping Forceps, for FISCH Titanium Incus Prosthesis
Holding Forceps, for FISCH Titanium Incus Prosthesis
FISCH Micro Hook, for transporting and positionIng
the FISCH Titanium Incus Prosthesis
Scissors, for FISCH Titanium Total Prosthesiss
Holding Forceps, for FISCH Titanium Total Prosthesis
843016 F 842016 F 516013
Diamond Burr, 1.4 mm, 7 cm,
Bipolar Coagulating Forceps, angular, tip 0.4 mm,
insulated, length 16 cm
Bipolar Coagulating Forceps, angular, 0.2 mm, insulated handle,
non-insulated from angle to tIp, length 16 cm
Bipolar Coagulating Forceps, angled t ip, pointed,
t ip 0.4 mm, insulated, length 16 cm
Needle Holder, tungsten carbide inserts, lengt h 13 em
SHEA Vein Press, 13 cm
FISCH Glass Cutting Board
55
227526
227900
.
231009
56
FISCH TITANIUM Middle Ear Prostheses
227510
227511
227512
227520
1. 1.
FISCH TITANIUM St apes Pist on,
short distance between loop and
cylinder, 7.0 x diam. 0.4 mm,
short size, sterile
FISCH TITANIUM Stapes Pi st on,
medium distance between loop and
cylinder, dia. 8.5 x dlam. 0.4 mm,
normal size, sterile
FISCH TITANIUM Stapes Pi st on,
long distance between loop and
cylinder, dia. 10.0 x diam. 0.4 mm.
long size, sterile
FISCH TITANIUM Tot al Prosthesi s,
wllh foot, 10.0 x diam. 0.6 mm, sterile
227515
227516
227517
227522
FISCH TITANIUM Incus Prosthesi s,
3.0 mm (1.31 diam. 2.0 mm),
normal size, sterile
FISCH TITANIUM Incus Prosthesis.
4.0 mm (1.31 dlam. 2.0 mm),
long size, sterile
FISCH TITANIUM Incus Prosthesi s,
5.0 mm (1.31 diam. 2.0 mm),
extra long size, sterile
FISCH TITANIUM Neomalleus
Prosthesis, 5.0 x diam. 1.1 mm,
sterile
Tempo
Meta
Metal Tray for Sterilizing and Storage of Ear Instruments
239728 Metal Tray, for sterilizing and storage of ear
instruments, perforated, bottom part with
holder for 20 straight ear micro instruments
with octagonal handle type 223300, lid with
silicone bridges. external dimensions
(w xd x hl: 285 x 175 x 36 mm
57
58
UNIDRIVE ENT
The multifunctional unit for otorhinolaryngology
a
Special Features and Specifications
One unit - six functions:
- Shaver system for surgery of the paranasal sinuses and anterior skull base
- INTRA Drill
- Sinus Burr
- Micro Saw
- STAMMBERGER-SACHSE Intranasal Drill
- Dermatome
Two outputs:
Two motor outputs enable to connect two motors simul taneously. For example an
intranasal drill and a paranasal sinus shaver or two INTRA drill hand pieces may be
connected in parallel.
New integrated irrigation and coolant pump:
Absolutely homogenous, micro-processor controlled irrigation rate throughout the
entire irrigation range. Quick and easy connection of the tubing set.
Touch Screen:
Straightforward function selection via touch screen. The unit stores the parameter
values of the function selected during the last operation session.
Optimized user control via touch screen
Operating elements are simple and clear to read due to color display
Irrigator rod included
Continuously adjustable revolution range
Maximum number of revolutions and motor torque:
The set parameters are maintained throughout the drilling procedure by the micro-
processor controlled electronic motor.
Maximum number of revolutions can be preset
,.. . model with connections to the KARL STORZ Communication Bus System
Tempora
UNIDI
Specific
UNIDRIVP ENT
Specifications
Shaver Mode
Operat ion mode:
Maximum revolutions (min '):
Sinus BUrT Mode
Operation mode:
Maximum revolutions (min '):
Drilling mode
Operation mode:
Maximum revolut ions (min 'I:
Micro saws mode
Maximum revolut ions (mi n 'I:
Intranasal Drill mode
oscillating
in conjunctiOn with Micro Shaver Handpiece 40 71 10 35
in conjunction with Paranasal Sinus Shaver Handpiece 40711039
in conjunction With OriliCut-X Shaver Handpiece 40 7110 40
rotating
in conjunction with OrillCul -X Shaver Handpiece 40 711 0 40
counter clockwise or clockwise
in conjunction wilh EC micro motor 20 711032
in conjunction wilh EC micro motor 20 711032
Maximum revolut ions (min '): in conjunction wi th EC micro motor 20 71 1 0 32
Dermatome mode
Maximum revolut ions (min '): in conjunction with EC micro motor 20 711 0 32
Touch screen:
Power supply:
Dimensions (w x h x d):
Weight:
Two outputs f or parallel
connection of two motors
Integrated irrigation pump
Flow:
Available languages:
20 711032
6.4"/300 cd/m'
100 - 120, 230 - 240 VAC, 50/60 Hz
304 x 164 x 263 mm
6,1 kg
15 - 125 ml/min.
English, French, German, Spanish, Iialian, Portuguese, Greek,
Turkish Certified to: lEG 601-1 GE, according to MOD
20 711 0 72
Spec ial features of the high performance EC micro motor with INTRA coupling:

Self-cooling, brushless high

INTRA coupling enables a wide
performance EC micro motor variety of appl ications

Smallest possible dimensions

Maximum torque 4 Ncm

Autoclavable

Number of revolutions can be

Detachable connecting cable
continuously adjusted from
o - 40,000 rev./mln.
3.000
7.000
7.000
12.000
40.000
20.000
60,000
8.000
59
60
UNIDRIVE ENT
System Configurations recommended by KARL STORZ
B
00
20 711620'
40 711601-1 UNIDRIVE ENT
consisting of:
20 711620-1 UNIDRIVE ENT with KARL STORZ-SGB
100 - 120, 230 - 240 VAC, 50160 Hz
400 A Mains Cord
20 012630 Two-Pedal Footswit ch, two-stage,
with proportional function
20 711640
20 711621
20 090170
Silicone Tubing Set, for irrigation, sieriiizable
Clip-Set, for use wit h tubing set 20 71 1640
SGB Connecting Cable, length lOa em
Accessori es:
20 711032
20 711072
280052 B
260052 C
mtp
High Performance EC Mi cro Motor
Connecting Cable, to connect EC molor 20 7110 32
to control unit
Universal Sprayer, 0.5 I bottle, for use with 280052 C,
- HAZARDOUS GOODS - UN 1950
Spray Diffuser, for use with 280052 B
Set of Tubes, for single patient use
*) This product is marketed by mtp.
For additional information, please apply t o:
~
mtp medical technical promotion gmbh,
p.o. box 4529,78510 Tuttlingen, Germany
Email: info@mtp-tut.de
Tempora
UNIDI
System
PA
UNIDRIVE ENT
System Components
U NIT SIDE
PATIENT SIDE
INTRA Drill t l ~ l l c e
-
Two _al Foonw+tcll
-

00
207110:12
20 1110n
1
2$4000 - 2$4300
61
Silic:onor TuI>Ing Sel
I
I I
20 711640
62
INTRA Drill Handpiece
Special Features:
Tool-free closing and opening of the drill light construction
Right/left rotation
Operates with littl e vibrations
Max. rotating speed up to 40,000 min '
low maintenance , easy cl eaning
Detachable irrigation channels
252475
252495
252490
280052
Safe grip
252475
INTRA Drill Handpiece, angled, 12.5 em, for use with
straight shaft burrs, transmission 1:1 (40,000 rpm)
252495
INTRA Orill Handpiece, straight, long shape, 10.4 em, for
use with straight shaft burrs, transmission 1: 1 (40,000 rpm)
252490
INTRA Drill Handpiece, st raight, 8.7 em, for use with
straight shaft burrs, transmission 1:1 (40,000 rpm)
280052
Universal Spray, combination cleaner and lubricant , for INTRA Drill
Handpiece and EC motors, package of 6 sprayers 280052 Band
1 spray diffuser 280052 C - HAZARDOUS GOOD - UN 1950
Tempora
Burrs
Straight
Burrs
Strai ght Shaft Burrs, l ength 7 em
Size Dia. mm
006 0.6
007 0.7
008 0.8
010 1.0
014 1.4
018 1.8
023 2.3
027 2.7
031 3.1
035 3.5
040 4.0
045 4.5
050 5.0
060 6.0
070 7.0
260000
261000
262000
262200
280030
7.0 em
Standard
Tungsten Transverse
Diamond
Carbide Tungst.Carb.
260006 261006 262006
260007
262007
260008 261008 262008
260010 261010 262010
260014 261014 261114 262014
260018 261018
262018
260023 261023 261123 262023
260027 261027 262027
260031 261031 261131 262031
260035 261035 262035
260040 261040 261140 262040
260045 261045 262045
260050 261050 261150 262050
260060 261060 261160 262060
260070 261070 262070
Standard Straight Shaft Burrs,
length 7 em, sizes 006 - 070, set of 15
Tungsten Carbide Shaft Burrs,
Diamond
coarse
262223
262227
262231
262235
262240
262245
262250
262260
262270
Diamond Straight Shaft Burrs, with smooth shaft,
Rapid Diamond Straight Shaft Burrs, with coarse
diamond coating for precise drilling and abrasion by light
hand pressure. generating minimal heat. length 7 em,
sizes 023 - 070, set of 9
Rac k, for 36 straight shaft burrs with a length of 7 em,
can be folded out, sterilizable. 22 x 1 1.5 x 2 em
63
64
Burrs
Straight Shaft Burrs, length 5.7 em
0
(0
0
0
0
0
0
0
0
0
0
Straight Shaft Burrs
oblong, length 1 em
Size
014
018
023
027
031
035
040
045
050
060
070
649600 K
649700 K
649700 GK
5.7 em
e=
Dia. mm Standard Diamond
Diamond
coarse
1.4 649614 K 649714 K
1.8 649618 K 649718 K
2.3 649623 K 649723K 649723 GK
2.7 649627 K 649727 K 649727 GK
3.1 649631 K 649731 K 649731 GK
3.5 649635 K 649735 K 649735 GK
4.0 649640 K 649740 K 649740 GK
4.5 649645 K 649745 K 649745 GK
5.0 649650 K 649750 K 649750 GK
6.0 649660 K 649760 K 649760 GK
7.0 649670 K 649770 K 649770 GK
Standard Straight Shaft Burrs,
stainless steel. length 5.7 em, sizes 014 - 070,
setofl1
Diamond Straight Shaft Burrs,
stainless steel, lengt h 5.7 em. sizes 014 - 070,
set of 11
Rapid Diamond Straight Shaft Burr, stainless,
with coarse diamond coating for precise drilling
and grinding without applying pressure with
minimal heat buildup. length 5.7 em,
sizes 023 - 070, set of 9
265050 - 265070
Size Oia. mm Standard
050
060
070
5.0
6.0
7.0
265050
265060
265070
Tempora
Burrs
lINDEM
length 7
Olamon
length "I
Oiamon
length;
Burrs
LINDEMANN Conical, stainless,
length 7 em
Diamond Straight Shaft Saw,
length 7 em
Diamond Saw Drill ,
length 7 em
280090
Size Oia. mm Standard
018
021
023
1.8
2.1
2.3
263518
263521
263523
Size Dia. mm Standard
008
OlD
015
0.8
1.0
1.5
267008
267010
267015
Size Dia. mm Standard
008
OlD
015
0.8
1.0
1.5
280090
268008
268010
268015
269000
Hole Gauge, for burrs, stainless,
autoclavable
65
66
Tempor
Burrs - Accessories Burrs
280010 Rack, with lid for 34 straight shaft burrs with 7 em shafts, sterilizable,
19.5x 9.5 x4 em
280080
280120
280030
280030 K
280080
280120
Brush, for cleaning burrs, sterilizable, package of 5
Temporal Bone Holder, bowl-shaped, with 3 fixat ion screws for tensioning
the petrosal bone and wit h evacuation tube for irrigation liquid, incl. weight
plate 280121 for stabilization of the bowl and rubber ring 8575 GKR for
base to prevent sl ipping
280030
Rack, for 36 st raight shaft burrs with a lengt h of 7 em.
can be folded Qut , sterilizable, 22 x 11.5 x 2 em
Metal bar, for fixation at rack 280030.
to hold 18 burrs with a lengt h of 7 em and 16 burrs
with a length of 5.7 em, size 16 x 2.5 x 1 em
280030 K
-
Temporal Bone Dissection - The Zurich Guidel ines
Burrs - Accessories
39552 A
39552 B
39552 A

' ..

: ..
. . :
Including basket for small parts
Sterilizing and Storage Basket, provides safe storage of accessories for
KARL STORZ drilling/grinding systems during cleaning and st erilization,
includes basket for small parts, for use with rack 280030, rack not included
for st orage of :
- Up to 6 drill handpieces
- Connecting cable
- EC micro motor
- Small parts
Sterilizing and Storage Basket, provides safe storage of accessories for
KARL STORZ drilling/grinding systems during cleaning and sterilization,
Includes basket for small parts, for use with rack 280030, rack included
f or storage of:
- Up to 6 drill handpieces
- Connecting cable
- EC micro motor
- Up to 36 drill bit s and burrs
- Small parts
67

Temporal Bone Dissection - The ZURICH Guidelines

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